First name
Last name
Date of Birth
Physicians Name
Physicians Phone
Emergency Contact
Do you eat at regular times each day?
How many days a week do you eat a morning meal?
...a lunch or midday meal? evening meal?
... a meal during the night?
How many days a week do you have snacks in the mid-morning? the mid-afternoon? the evening?
...during the night?
Which meals do you usually eat with your family?(hold ctrl to select more than one)
How many times per week do you eat in a restaurant or cafeteria?
How would you describe your appetite
At what time of the day are you most hungry?
What are the foods you dislike?
Are you on a special diet now?
If yes, why are you on a diet?
If no, have you been on a diet in the past year?
If yes, why?
How many times per week do you eat the following: (number0-7 or greater)
Luncheon Meat
Hot Dogs
Pork or Ham
Beef or Veal
Other Meat
Meat in mixtures (stews, caseroles, tamales, etc.)
How many times per week do you eat the following: (number0-7 or greater)
Fruit Juice
Dry Cereal
Cooked Cereal or Instant
Pancakes or Waffles
Cooked Vegetables
Raw Vegetables
Ice Cream, Milk, pudding, custard, or cream soup
Macaroni, Spaghetti, rice, noodles
Dried beans or peas
Peanut Butter or Nuts
crackers or pretzels
Sweet rolls or doughnuts
Pie, Cake or Brownies
Potato Chips or Corn Chips
Soft Drinks, Popsicles or Kool-Ad
Instant Breakfast
Alcoholic Beverages
How many servings per day do you eat the following: (number0-7 or greater)
Bread, Toast, Rolls, Muffins (1 slice or piece = 1 serving)
Milk (including on ceral or other foods (8 oz. = 1 serving)
Sugar, jam, jelly, syrup (1 teaspoon = 1 serving)
What specific kinds of the following foods do you eat most often(hold cntrl to select more than one)?
Have you done any type of exercise before? if so, what?
Did you ever play any type of sports? Or do you presently?
Are you currently Participating in any physical activities?
Would you classify your daily eating habits as healthy.
What goals and objectives have you set up for yourself?
What are your thoughts on fat loss versus weight loss?
How do you feel about working out?
How do you feel about taking instruction from someone else?
How would you describe yourself?
What time and effort are you willing to put into your health objectives?
What are your thoughts on spot reducing?
How do you feel about slow gradual changes to your body?
Are you ready to change some of your health and wellness behaviors?
How would you describe a typical day in your life?
How would you describe a typical week in your life?
What activiities or hobbies do you enjoy?
On a scale form 1 to 5 (5=most physical), what is your daily physical activity level?
Beginning with most important, list and rate your goals into long and short term?
Do you have any support other than yourself to help you reach your objectives?
What do you think may stop you from reaching your health goals
Talk about your past attempts at dieting and exercise?
How would you describe your health presently?
List the medications you are currently taking?
Are you pregnant or have you been in the past 3 months?
Has a physician or any allied-health professional advised against you participating in an exercise program?
If yes, explain.
Please indicate if the following conditions reate to your or your family.
History of heart problems
High Blood Pressure
Difficulty with physical exercise
A chronic illness
Muscle, joint, or back disorder that could be aggravated by physical activity
Recent (within a year) surgery
History of lung problems
History of diabetes
Cigarette smoking habit
If so, how many per day? How long have your smoked?
Obesity (>30% of ideal weight)
High blood cholesterol
If so, what type?
Do you have any problems with soft tissue?
Have you ever had joint injuries? (Hold cntrl to select more than 1)
What regular physical activities do you currently engage in?
What realistic commitment are you willing to make to your exercies and health?
Enter the shown code: