Client Profile Questionnaire Date: MM slash DD slash YYYY Name:* Street Address: City, State Zip: Home Phone:Work Phone:*Mobile Phone:Email:* Emergency Contact: General Health and Nutrition Questions Personal Profile InformationGender:MaleFemaleBirth Date: MM slash DD slash YYYY Height: Weight: Body Fat%: Weekly Exercise Information Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period.Exercise or Activity Days per Week Duration Exercise or Activity 2 Days per Week 2 Duration 2 Exercise or Activity 3 Days per Week 3 Duration 3 Exercise or Activity 4 Days per Week 4 Duration 4 Exercise or Activity 5 Days per Week 5 Duration 5 Exercise or Activity 6 Days per Week 6 Duration 6 Exercise or Activity 7 Days per Week 7 Duration 8 Lifestyle / Professional ActivityHow would you rate the activity level of your profession, or what you do during the day (non-exercise related).SedentaryModerately ActiveActiveVery Active What are your goals?What are your goals? Weight Loss Maintain /Improve Eating Habits Gain Weight What is your goal weight? Protein RequirementsWhich best describes you? Sedentary Adult Exercising Adult Competitive Athlete Growing Teenage Athlete Adult Building Muscle Athlete Restricting Calories Body TypeWhich of the following statements best describes you?I can eat practically anything I want and I don not gain weight. I find it very hard to gain weight.I can lose or gain weight by adjusting my activity level and eating habits.I find it difficult to lose weight. I can gain weight easily and have to watch what I eat. Health & Medical ConditionsCheck any that apply or describe any other(s). Heart Disease Anemia Hypoglycemia Liver Disease Kidney Disease Diabetes Pancreatic Disease Lactation Hypertension Any others? Make a list of your favorite foods.Make a list of foods that you dislike.What time do you normally wake up? What time do you normally go to bed at night? If you smoke, how many per day? If you smoke, how many years have you smoked? If you drink alcoholic beverages, what and how many per day?List any types or kinds of foods that you are allergic to? Have you ever been placed on any type of nutritional program in the past?NoYesIf yes, by whom and what did it consist of? Please explain below.What were your results? Have you ever had your body fat tested?NoYesIf yes, how was it tested and when? Exercise HistoryAre you currently involved in a regular exercise program?NoYesDo you regularly walk or run 1 or more miles continuously?NoYesIf yes, what is the average number of miles you cover in a workout?1234567891011121314151617181920What is your average time per mile in minutes?56789101112131415161718192021222324252627282930+Do you practice weightlifting or calisthenics?NoYesAre you involved in an aerobic program?NoYesIf yes, what type of aerobic program? Do you frequently compete in competitive sports?NoYesIf yes which one(s)? Golf Volleyball Bowling Football Tennis Baseball Handball Track Soccer Basketball Walking Running Bicycling (outdoors) Swimming Stationary Running Stationary Biking Tennis Jumping Rope Handball Basketball Squash List any others? Average number of times per week?1234567891011121314151617181920In which of the following high school or college athletics did you participate? None Track Football Swimming Basketball Tennis Baseball Wrestling Soccer Golf List any others? Additional Comments: Patient Health History Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:Head/Neck: Upper Back: Shoulder/Clavicle: Arm/Elbow: Wrist/Hand: Lower Back: Hip/Pelvis: Thigh/Knee: Arthritis: Hernia: Surgeries: Other: Patient Nutrition and ExerciseAre you on any specific food/diet plan at this time?NoYesIf yes, please list:Do you take dietary supplements?NoYesIf yes, please list:Do you experience any frequent weight fluctuations?NoYesHave you experienced a recent weight gain or loss?NoYesIf yes, list change:In what period of time? How many beverages do you consume per day that contain caffeine?12345678910+How would you describe your current nutritional habits?Other food/nutritional issues you want to include (food allergies, mealtimes, etc.):Select what best describes your work and exercise habits.Intense occupational and recreational exertionModerate occupational and recreational exertionSedentary occupational and intense recreational exertionSedentary occupational and moderate recreational exertionSedentary occupational and light recreational exertionComplete lack of all exertionTo what degree do you perceive your work environment as stressful?MinimalModerateAverageExtremelyTo what degree do you perceive your home environment as stressful?MinimalModerateAverageExtremelyDo you work more than 40 hours a week?NoYesPlease make any other comments you feel are pertinent to your exercise program.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.