Client Profile Questionnaire Date: Name: Street Address: City, State Zip: Home Phone: Work Phone: Mobile Phone: Email: Emergency Contact: General Health and Nutrition Questions Personal Profile Information Gender: MaleFemale Birth Date: 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 Lifestyle / Professional Activity How 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? Weight LossMaintain /Improve Eating HabitsGain Weight What is your goal weight? Protein Requirements Which best describes you? Sedentary AdultExercising AdultCompetitive AthleteGrowing Teenage AthleteAdult Building MuscleAthlete Restricting Calories Body Type Which 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 Conditions Check any that apply or describe any other(s). Heart DiseaseAnemiaHypoglycemiaLiver DiseaseKidney DiseaseDiabetesPancreatic DiseaseLactationHypertension 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? NoYes If yes, by whom and what did it consist of? Please explain below. What were your results? Have you ever had your body fat tested? NoYes If yes, how was it tested and when? Exercise History Are you currently involved in a regular exercise program? NoYes Do you regularly walk or run 1 or more miles continuously? NoYes If yes, what is the average number of miles you cover in a workout? 1234567891011121314151617181920 What is your average time per mile in minutes? 56789101112131415161718192021222324252627282930+ Do you practice weightlifting or calisthenics? NoYes Are you involved in an aerobic program? NoYes If yes, what type of aerobic program? Do you frequently compete in competitive sports? NoYes If yes which one(s)? GolfVolleyballBowlingFootballTennisBaseballHandballTrackSoccerBasketballWalkingRunningBicycling (outdoors)SwimmingStationary RunningStationary BikingTennisJumping RopeHandballBasketballSquash List any others? Average number of times per week? 1234567891011121314151617181920 In which of the following high school or college athletics did you participate? NoneTrackFootballSwimmingBasketballTennisBaseballWrestlingSoccerGolf 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 Exercise Are you on any specific food/diet plan at this time? NoYes If yes, please list: Do you take dietary supplements? NoYes If yes, please list: Do you experience any frequent weight fluctuations? NoYes Have you experienced a recent weight gain or loss? NoYes If 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 exertion To what degree do you perceive your work environment as stressful? MinimalModerateAverageExtremely To what degree do you perceive your home environment as stressful? MinimalModerateAverageExtremely Do you work more than 40 hours a week? NoYes Please make any other comments you feel are pertinent to your exercise program.