Client Questionnaire

OUR PROGRAMS ARE ROOTED IN
OUR CORE VALUES!

Honesty- a refusal to lie, steal, or deceive in any way.
Honor- an active or anxious regard for the standards of one's profession, calling or position.
Integrity- the ability to adhere to a code of especially moral or artistic values.
Professionalism- the conduct, aims, or qualities that characterize your attitudes and performance.
Excellence- the virtues, values and qualities one aspires to possess far and above the norm.

Diet and Nutrition Analysis

The key to the success of any activity and wellness program is the strength of the nutritional program that accompanies it. The success factor for activity, and training, from a beginner to an elite athlete is the success of their dietary plan. Through education, expert knowledge, follow through and the latest computer modeling technology, lifestyle recommendations and modifications can be made. Programs include One on One Consultations and follow up visits. Personal Education for the Individual in the Home. In home intervention, and education ie; Planning shopping lists, food preparation and “the closet hunt” .Internet consultation available

REALITY PERSONAL TRAINING
NUTRITION QUESTIONNAIRE

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Business Phone:
Fax:
E-mail Address:
Have you had any illnesses in the past 10 years?
Please List
Are you currently taking any medications?
If Yes Please List
What was your blood pressure at your assessment? (or if you know your last reading)
Do you know your cholesterol?
If YES, please enter:
Please List Your Family's Health History
LIFESTYLE
How many times a week do you exercise?
Please explain your current exercise regimen:
Do you smoke?
If Yes how much?
Do You Drink Alcohol?
If YES how much?
Is your energy lower now than it used to be?
How many times a week do you eat out in restaurants and what type of food?
Do you eat fast food?
How Often?
Where do you eat fast food?
If OTHER please specify
Do you have difficulty sleeping?
How many hours a night do you sleep?
DIET ANALYSIS
How many meals do you eat per day?
How often do you eat products made with white flour? (breads, cereal, etc)
How many teaspoons of sugar do you add to food or drink per day?
Do you use sugar substitutes?
If YES, which sugar substitutes?
Do you add salt to foods?
How many cups of coffee do you drink per day?
How many cups of tea?
How often do you drink soda, iced tea, juices etc?
How many glasses or how many ounces of water per day ?(please specify)
How often do you eat red meat?
How often do you eat fruit & vegetables?
How often do you eat dairy products & is it low fat? (milk, cheese, yogurt)
How many times a week do you eat eggs?
How often do you eat cake & cookies?
Candy?
Ice Cream?
Do you frequently eat under stressed or emotional conditions?
Do you skip meals frequently?
Is there a time during the day when you crave a specific type of food?
If YES, please enter time and which food:
How would you describe your appetite? (e.g.; good, fair, poor)
Have you tried fad diets in the past? Which ones?
Do you take nutritional supplements or vitamins? Please indicate: Yes or No and specifics including product manufacturer.
What are your food preferences/likes?
What are the foods you dislike?
Please write the food and drink you might consume in a “typical” day and the time of the meal.
Breakfast	Time Food
Snack	Time Food
Lunch	Time Food
Snack	Time Food
Dinner	Time Food
Snack	Time Food