Let us create a personalized fitness program just for you.
We have provided a comprehensive questionnaire for you to fill out in order to evaluate which of our custom fitness programs is right for you! If you have any questions, contact your patient coordinator

1. Contact Information:
First Name:
Last Name:
E-mail address:
Address 1:
Address 2:
Zip Code:
Home Phone: (Include area code)
Bus. Phone: (Include area code)
2. General Information:
Gender: Male: Female: Height: Date of Birth:
Current Weight: Desired Weight:
Bone Structure:    Small     Medium     Large
Activity Level:     Very Low     Low     Medium     High     Very High
Do you smoke?    No     Yes     If Yes, cigarettes per day
Do you drink alcohol?    No:     Yes:
If Yes, what is your consumption?
Beer: oz./week   Wine: oz./week   Liquor: oz./week
3. Fitness Goals
Increase Muscle Reduce Fat level Tone Up Increase Energy
Areas you would like to focus on:
Number of days per week available for training:
4. Training Schedule
Which days of the week would you like to weight train?
Mon / Tue / Wed / Thur / Fri / Sat / Sun
How much time can you devote to each weight training session?
30 min. 45 min. 60 min. Other:
What type of cardiovascular exercise do you prefer?
Cycling Stepper Treadmill Running Other:

What training methods worked best for you in the past?

List any other information that you consider relevant:

5. Dietary Habits
Have you tried dieting before?
   If Yes, What have you tried?
Are you allergic to any foods?
   If Yes, What are your food allergies?
Do you have a lactose intolerance?
Are there any foods you refuse to (or do not) eat?
    If Yes, please describe:
Which of the following meals do you currently eat, and at what time do you eat them?
Breakfast Time Morning Snack Time
Lunch Time Afternoon Snack Time
Dinner Time Evening Snack Time
Prefer protein (meat, fish, poultry, etc.)?
Prefer carbs (pasta, rice, potatoes, fruits, sweets, breads, etc.)?
Prefer fats (sauces, butter, fried foods, bacon, sausage, etc.)?
Please indicate any regular eating habits you have (i. e. dining out on weekends,
late night eating, cravings, etc.):

Please list ALL the foods you have eaten in the last forty-eight hours:
How many 8 oz. glasses of water (excludes soda, coffee, tea, etc.)
do you drink each day?
Enter Average per Day:
How many meals per day do you eat? 3 4 5 6 7

Do you have any comments, questions, or concerns regarding the programs?


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