Read each question
carefully. Complete or fill in the circle of the best answer from the choices
given. Thank you. Bring with you to your appointment.
1. What is your fitness/health goal?
_______________________________
2. What is your current occupation?
____________________________
2a. Mark
the one that applies best:
j Full-time
k Part-time
l Not working/retired
2b.
Mark if doing shift work ™ Shift work
3. In the last five years, what was your highest
weight? _______ (lbs)
4. What was your lowest weight? _______ (lbs)
5. What is your desired weight? _______
(lbs)
6. What is your current weight? _______
(lbs)
7. What is your height? ____ft ____
in
8. Family history Select any of the following health
problems found in your immediate family (parent, brother, sister).
j colorectal cancer
j
breast cancer
j
ovarian cancer
j
prostate cancer
j
high blood
pressure
j
high cholesterol
j
osteoporosis
j
diabetes
j
stroke
j
coronary heart
disease, heart attack, or coronary surgery before age 55 in men, or before 65
in women
j
high
triglycerides
j
stomach/GI
problems
j
weight problems
j
I donÕt know my
family history
9. Mark the general health status of
those you live with (if you live alone, skip to question 10).
1. Spouse - j Good k Fair l Poor
2. Partner j Good k Fair l Poor
3. Infant Ð ( < 1 year) j Good k Fair l Poor
4. Son(s) Ð (child < 13) j Good k Fair l Poor
5. Son(s) Ð (teen 13-20) j Good k Fair l Poor
6. Son(s) Ð (adult 20+) j Good k Fair l Poor
7. Daughter(s) Ð (child < 13) j Good k Fair l Poor
8. Daughter(s) (teen 13-20) j Good k Fair l Poor
9. Daughter(s) Ð (adult 20+) j Good k Fair l Poor
10. Other(s) j Good k Fair l Poor
10.
Personal history Do you have any of the following conditions? Mark all that apply.
|
j allergies
|
j high blood pressure
|
|
j anxiety disorder
|
j asthma or bronchitis
|
|
j sleep disorder
|
j diabetes
|
|
j emphysema (COPD)
|
j high cholesterol
|
|
j heart disease
|
j back pain
|
|
j migraine headaches
|
j skin cancer
|
|
j depression
|
j other cancer
|
|
j osteoporosis
|
j gout
|
|
j pregnant (women)
|
j kidney disease
|
|
j arthritis
|
j thyroid problems
|
|
j anorexia/bulimia
|
j polycystic ovary disease
|
|
j high triglycerides
|
j stomach/GI problems
|
j List other (if any) ___________
11. What medications are you currently
taking?
____________________________
____________________________
____________________________
1. Do you have any dietary preferences (such as eating
vegetarian) or some restriction (such as a food allergy) that may limit your
food choices?
j Yes (please mark list below)
j No (please skip to question 2)
Preferences
Pleases indicate the dietary
restriction(s) or preference(s) below. Mark all that apply to you.
j a - Strict Vegetarian or Vegan Ð will not eat any animal products such as
meat, poultry, seafood, milk (milk products) or eggs.
j b - Lacto-ovo vegetarian Ð will
not eat animal product such as meat, poultry or seafood but will eat eggs and
milk products such as yoghurt and cheese.
j c - Other vegetarian Ð will not
eat most animal products but will eat some.
j d - Medical
restriction Ð have a medical condition where my doctor has limited certain
foods or has given me a special therapeutic diet.
e - List name of condition(s) here
_________________________________
j f - Milk intolerance Ð have a milk allergy and avoid many or all milk
products.
The following questions are about
your current eating habits and the specific foods you eat. Your answers will
help to identify opportunities for improvement and assist with developing a
personalized meal plan.
2. On most days, how many meals do you
eat?
_____ per day Snacks ______per day
3. How many of those meals are usually
prepared by you or someone in your household?
_____ per day
4. How many meals per week do you usually eat out? Count meals
prepared by a commercial food service, restaurant, deli or fast food provider.
_____ per week
5. Breakfast - How often do you eat breakfast?
j everyday
k most days
l some days
m rarely or never
6. Skip meals - How often do you skip a meal?
j everyday
k most days
l some days
m rarely or never
7. Night eating - How often do you eat a meal or snack
less than 2 hours before bedtime?
j everyday
k most days
l some days
m rarely or never
8. Appetite Ð How do you rate your appetite or
desire for food?
j very good
k good
l not always good
m poor most of the time
9. Satisfied - How often do you stop eating after
you feel you have eaten enough?
j always
k most of the time
l some of the time
m rarely or never
10. Binging, is to lose control by eating a
large amount of food over a short period of time. Do you ever binge?
j Yes j No (skip to question 12)
11. How many times per week?
_____ per week
12. Water - Think about what you drink all during the day. How
many cups (8 oz cup) of water or other non-caffeinated beverages such as juice
do you have on most days (do not count tea, coffee, beer or other alcoholic
beverages)?
_____ per day
13. How many caffeinated beverages
do you drink each day? Please include regular tea, coffee, espressos, lattes,
or caffeinated soft drinks.
_____ per
day
14. Alcohol - Have you had any alcoholic
beverages in the last 6 months?
j Yes j No (skip to question 16)
15. How many drinks of beer, wine or liquor do you regularly
have per week? (one drink is 3 to 5 oz. wine, 10 oz wine cooler, 12
oz beer or 1.5 oz liquor)
_____ drinks per week
16. Milk preferences -
Which statement best
describes the fat content of milk you would choose to drink?
j Only regular whole milk (about 4%
fat)
k Both regular whole milk and low fat
milk
l Only low-fat milk (1 to 2 % fat)
m Both low-fat and non-fat milk
n Only non-fat milk (0.5% fat)
o Do not drink dairy milk
17.
Fat preferences - When
choosing foods for your meal, do you usually select, high-fat or low-fat foods?
After reviewing the examples, select the most appropriate response.
High-fat examples: hamburgers, sausages, luncheon
meat, marbled beef, sour cream, cheese, eggs, butter, pastry, ice cream,
full-fat dairy products, chocolate, fried foods and many fast foods
Low-fat examples: lean meats, skinless poultry,
fish, low-fat dairy products, fruit desserts, gelatin, vegetables, pasta, and
legumes (peas and beans)
j choose high-fat foods nearly all the
time
k choose high-fat foods most of the
time
l choose both high and low-fat foods
equally as often
m choose low-fat foods most of the
time
n choose low-fat foods all the time
18. Added salt - How often do you add salt to your
food?
j not at all
k occasionally (2 Ð 3 times per week)
l moderately (one meal per day)
m quite often (nearly every meal)
n majority of the time (on most everything)
19. Salty food - How often do you eat salty foods (such
as soy sauce, pickles, canned meats, salted nuts or potato or corn chips)?
j not at all
k occasionally
l moderately
m quite often
n majority of the time
20. Fiber preferences How often do you choose to eat
high-fiber foods such as whole wheat bread or pasta, high-fiber breakfast
cereal and brown rice?
j rarely or never
k occasionally
l sometimes
m majority of the time
n always
21. Supplements - Do you take nutritional
supplements, such as vitamins or herbs on a typical day?
j Yes j No (skip the next section)
List supplements Ð If you are taking supplements, list
them below.
_______________________
_______________________
_______________________
_______________________
_______________________
22. Smoking Ð Do you smoke cigarettes?
j Yes j No (skip to question 24)
23. How much do you smoke?
j
less than one pack a day
k
about one pack a day
l
more than one pack a day
24. Other tobacco Ð Do you use other tobacco?
j Yes j No
25. Diet History Ð Has a doctor ever prescribed a
special diet or food plan for you?
j Yes j No (skip the question 27)
26.
Please describe_______________________
27.
What other diets have you tried (e.g. Atkins, Jenny Craig)? ______________________
Exercise Assessment
1.
Judge your current
activity level. Activity levels indicate a person's normal daily routine. It
does not account for exercise. It is only concerned with what you do routinely
every day. This is normally associated with oneÕs job.
Lightly
Activity: This is the classification
that most people should be listed under. These are folks who sit down during
the day to perform their jobs. It also includes activities such as driving,
laboratory work, typing, sewing, ironing, cooking, playing cards, playing a
musical instrument.
Moderate
Activity: People who are on their
feet during most of their work day are moderately active people. This would
include occupations like waiters or waitresses, garage work, electrical trades,
house cleaning.
Heavy
Activity: These folks are very
active. They work in construction, move furniture, lift heavy loads, etc.
Very
Heavy Activity: These folks may be
amateur or professional athletes. They are doing very physical activity for
most of the day.
Select the
choice below that best describes your activity during a typical day (excluding
exercise)?
j Light:
k Moderate
l Heavy
m Very Heavy
2. Exercise History: Please indicate the type and amount of exercise you
are currently doing:
q Walking
q Running
q Cycling (outdoor)
q Aerobic classes
q Strength training
q Aerobic equipment
q ______________
q ______________
# Times/Week # Mins/Session
I walk _____________ ________________
I run/jog ______________ ________________
I cycle ______________ ________________
I take aerobics______________
________________
I strength train______________
________________
I use aerobic equipment______________
________________
Other ______________ ________________
3. Energy Level Ð How is your energy level during exercise?
j excellent
k good
l fair
m poor
4. Energy Level Ð Do you experience any of the following during exercise?
j nausea
k stomach cramps
l fatigue
m muscle cramps
3. Measurements (For Trainer Use)
Height __________ BF Triceps
_____
Weight __________ Waist
_____
Age __________ Thigh _____
Neck
Shoulders
Chest
Waist
Abs (BB)
Hips
Up Thigh R L
Low Thigh R L
Calves R L