Questionnaire
All new clients are requested to answer the following 21 questions beforehand. The information is used to determine your current physiology and metabolic state… to offer you the most accurate nutrition and exercise solution to achieve your fat burning or muscle building goal fast.
1. What is your immediate fitness goal? (Check only one).
- Burn Fat_____ Or Build Muscle_____
2. What is your current bodyweight? _____lbs
3. What is your height? _____ft _____in
4. If your goal is to burn fat and become lean:
- What is the body fat percentage you desire? _____Don’t know? _____
- If you don’t know, then explain how lean you want to become and what you want to achieve. ______________________________________________
- What is your current body fat percentage? _____Don’t know? _____
- If you don’t know, then explain as best you can how many pounds you think you have to drop where you will look and feel better. __________________________
5. What is your temperature first thing in the morning upon awakening? (Do not get out of bed and move around. Do not drink anything until afterwards.) _____fareinheit
6.How many times do you have a bowel movement?
- 1 or more times per day. Y_____ N_____
- 6 or fewer times per week (seven days). Y_____ N_____
- Are you ever constipated? Y_____ N_____
7.Record the foods you eat and add all the calories for a period of 3 consecutive days and write the total here. _____calories
8. Do you eat breakfast within 2 hours of awakening in the morning? Y_____ N_____
9. On a typical day what foods (if any) do you eat for breakfast? And the amount of it (if applies). ______________________________
10. What is your blood type? (Check one) 0_____ A_____ B_____ AB_____
11. If you had to make a choice would you prefer to eat a juicy steak or a mouthwatering cake? (Check one) Steak_____ Cake_____
12. If you are currently doing resistive exercise (weight lifting) on a typical day:
- How much time does your workout take to complete? _____
- How many sets do you perform per exercise? _____
- How many exercises do you perform per body part? _____
- How many days per week do you lift weights? _____
13. If you are currently doing aerobic exercise on a typical day:
- How much time does your workout take to complete? _____
- How many days per week do you exercise aerobically? _____
14. Do you like to crunch and suck on ice cubes? _____
15. Do you have a sweet tooth and crave sugary foods? Y_____ N_____
16. Do you crave fatty foods like potato chips? Y_____ N_____
17. If you’re on a calorie restrictive diet (below maintenance) how many days/weeks/months have you been doing it without taking a break (by eating maintenance calories or above)? _______________________________
18. Generally, how much water do you drink per day? (Do not include coffee, tea and sodas.) ___________________________________________________
19. Do you eat any diet foods or drink diet sodas that contain aspartame? (NutraSweet, Equal, Splenda) Y_____ N_____ If so, how much or how many? _____
20. List any vitamin, mineral and/or herb supplements and how long you’ve been using them. _________________________________________________________________
21. List any health issues that you think could hinder you from reaching your goal. (Diabetes, Hypo-thyroidism etc) ____________________________________________
If you have any questions or concerns just let me know…
Paul Reich
(fort worth)