Client Information Form
Name
First Name
Last Name
Email
example@example.com
Date of Birth
mo/day/yr
Gender
Male
Female
Height
Weight
Goals
Have you ever Participated in a Nutrition/Diet Program?
yes
no
Did you achieve those previous program goals?
yes
no
Which statement below is most important to you:
Immediate Progress that is easy to maintain
Maintainable Progress that may not be as rapid
How many times/week do you exercise?
ex.daily, weekly, never
Exercise/Activity Level
None
Moderate
High
What time of the day do you work?
Mornings
Afternoons
Evenings
How often do you travel?
Rarely
Few times/month
Weekly
Yearly
How often do you grocery shop?
Daily
Weekly
Monthly
Other
How often do you eat out at restaurant/fast food places per week?
My current diet could be best characterized as: (select one)
Low Fat
Low Carb
High Protein
Vegan
None
Do you have trouble sleeping at night?
yes
no
Number of cigarettes per day
Number of cups of coffee per day
Number of sodas per day
Number of glasses of water per day
List any physical activities you are participating in and outside of work and the gym
Medical Questions : Please list any health problems
Do you have any injuries?
yes
no
If yes, list below:
If you are on any medications, please list below:
Please list dietary supplements and over-the-counter medications below:
Have you had any heart troubles or Coronary Disease?
yes
no
Do you have a history of High Blood Pressure?
Yes
No
Do you have Diabetes?
Do you think you are Overweight?
Yes
No
Miscellaneous- Is there anything else I may need to know or you would like me to know?
Submit
Should be Empty: