Name :

E-Mail :

Age :

Gender :

Female

Height :

. 4' 10" 4' 11" 5' 0" 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 0"

Weight :

lbs (1kg = 2.2 lbs)

Elbow Breadth :

. Less than 2.25" Between 2.25" - 2.5" Greater than 2.5" Less than 2.375" Between 2.375" - 2.625" Greater than 2.625" Less than 2.5" Between 2.5" - 2.75" Greater than 2.75"

Your Body Fat percentage % :

%

(Know your Body Fat%)

Are you pregnant or plan to be in the near future :

Yes No

Are you breastfeeding and your child is under 6 months of age?

Yes No

Are you breastfeeding and your child is 6 months of age or older?

Yes No

Have you

(please select if you have or have ever had) :

High blood pressure

Heart disease

Diabetes

High Cholesterol level

High tri-glyceride level

Anemia

Arthritis

Asthma

Osteoporosis

Breast Cancer

If Other (please explain)

Make a choice of your health & fitness Goals :

Lose weight
Gain weight
Improve nutritional status
Maintain weight
Become more fit
Increase strength
Look better

While on a weight loss program, I would like to lose weight at a rate of :

˝ lbs /week
1 lbs /week
1˝ lbs/week
2 lbs/week

Receive regular updates on recent discoveries & trends in fitness industry :

Yes No.

Get great tips for fitting exercise in my schedule & making my progress as effective as possible in the time, I have available :

Yes No.

Have you tried diet programs or are you currently on one?

Yes No.

Do you need help decreasing amount of fat and sugar in your diet :

Yes No.

Do you need help in increasing fiber, vitamins & minerals in your diet :

Yes No.

Do you currently take nutritional supplements :

Yes No.

If so name:

Are you currently on a restricted diet?

(Check all that apply) :

Low fat / Low cholesterol

Low protein

Low sodium/low salt

Diabetic diet

Low fiber 

The following describes my eating habits :

I am a vegan
I am a lacto-vegetarian
I watch my calories
I watch my salt intake
I watch my cholesterol
I am a regular at restaurants.

How much water do you drink a day  (8 OZ. Glasses) :

1-3 4-6 7-8 9 or more...

The following describes my exercise routine :

Never
1-2 days/week
3-4 days/week
5 days or more

Is any cardiovascular exercise a part of your routine?

Yes No.

Have you ever done any kind of strength training until now?

Yes No.

If yes, then describe your strength training fitness level:

Do you include stretching in your workout program?

Yes No. 

I need support through :

Motivation
Tips on meal planning
Expert's advice
Emotional  counseling.

Your daily activity level :

Very inactive
Somewhat active
Moderately active
Very active

I am determined to achieve my goal weight :

Agree.
Slightly agree
Slightly disagree
Yes, please help me