Initial Client Information Questionnaire
This is your initial client information sheet, in which we will ask you to provide
some relevant personal information. The answers to these questions are essential in order
to allow us to design an optimized individual wellness program for you. Please answer all
questions in the most accurate manner possible while being as concise as possible.
Please recognize the fact that it is your responsibility to work directly with your physician
before, during, and after seeking fitness consultation. As such, any information provided
is not to be followed without the prior approval of your physician. If you choose to use this
information without the prior consent of your physician, you are agreeing to accept full
responsibility for your decision.
Date of Birth
Do you have any physical limitations, health issues, or injuries that I should be aware of when planning exercise or performance assessments?
Write "N/A" if none.
Do you have any food allergies, reactions, or medications that react with certain foods that I should be aware of before discussing nutrition options?
Write "N/A" if none.
My current diet could be best characterized as:
Check all that apply
No special diet
How many meals do you typically eat daily?
May be smaller, more frequent meals or less frequent, larger meals
How many meals do you eat in restaurants and/or fast food places per week?
How many pre-packaged (purchased/microwaveable) meals do you eat per week?
How many meals do you prepare at home per week?
Describe your living scenario and social setting for meals at home and/or with friends.
Do you live alone, with a spouse/significant other, or with friends? Do you have children and do they eat the same meals as you? Do you choose meals for your family based on what the other family members will like or what you think is healthy? Do you usually eat by yourself or with others in the home? Do you usually prepare the food or does someone else prepare the food in your home? Do you feel you should eat a certain way based on others or based on the social setting you're in? Who purchases the food in the home? Do you share food expenses/food with others in the home?
Describe your meal scenario/social setting at work.
Do you eat by yourself or with co-workers? Do you eat while you work or do you separate your meal/break times from work? Do you feel obligated to go out to eat with co-workers or eat similarly to co-workers? Do you have to grab food on the go due to work or travel? Do you keep snacks at your desk or workplace and if so what types? Do you have office meals/potlucks and how frequently? Do you or co-workers bring in shared food items? Does your job involve business transactions over meals or social gatherings?
Are there any diets or meal plans that you feel were successful with reaching your goals in the past?
Are there any diets or meal plans that you feel were unsuccessful or resulted in the opposite of your goals in the past?
Are you taking any nutritional supplements? Please list them below (type and dosage).
Please describe your general routine on the weekdays.
Include wake time, bedtime, work hours, meal times, exercise time, socializing activities, commitments, etc.
Please describe your general routine on the weekends.
Include wake time, bedtime, activities, outings, travel, socializing activities, exercise, meal times, etc.
Are you currently exercising regularly (at least 3x per week?)
Please describe typical weekly exercise or physical activities (type, frequency, and duration) including any exercise at work.
Resistance training exercises including strength workouts, weight-training, resistance bands, CrossFit; interval cardio bouts including stations, sprint intervals, short bursts of work/rest, tabata training; low-intensity cardio including jogging/running, walking, swimming, rowing, biking; sport-specific or recreational sport
Given the following goals, please check the three (3) that are most important to you.
Increased muscle mass
Do you have a specific target date for achieving a specific goal?
If no, please leave blank.
Over the past 3 months, which has been your weight pattern?
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