Weight & Nutrition Profile

How fit do you feel now?

What are your fitness goals?

Why are these goals important to you?

How committed are you to improving your fitness at this time?

What made you decide to make a change now?

What are your favorite exercise activities?

What types of exercise have you tried in the past?

Have you had any negative exercise experiences?

What is your current height and weight?
Height:    Weight: 

What would you like to weigh?: 

What is the most you have weighed as an adult?: 

What is the least you have weighed as an adult?: 

How long did you maintain this weight?: 

What is the lowest weight you have maintained for a year?: 

How many times have you lost and regained weight?: 

What types of diets have you tried?:

When were you last at your ideal body weight?: 

How would you describe your daily routine?:
Sedentary
Moderately Active
Active
Very Active

Which do you eat regularly?: (check all that apply)
Breakfast
Mid-morning snack
Lunch
Mid-afternoon snack
Dinner
After-dinner snack

How often do you eat out each week?:  Times

How often do you eat more than one serving?:
Always
Usually
Sometimes
Never

How long does it take you to eat a meal?:  Minutes

How many servings of the following foods do you eat each day?:
Fruit (1 small whole, or ½ cup)
Vegetables (1 cup)
Bread (1 slice)
Cereal (½ cup)
Pasta, rice or other grain (1 cup)
Dairy product (1 cup or 1½ oz.)
Meat (3 oz.)
Tofu (½ cup)

Are you satisfied with your current level of energy?:
Yes
No

Do you add salt to foods during cooking and at the table?:
Yes
No

Do you smoke cigarettes, cigars or chew tobacco?:
Yes
No

Do you drink alcohol?:
Yes
No
If yes, how often?: Times per week

What is your age?:  Years old

Additional comments/concerns: