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Nutritional Guidance: New Client Profile Form

Nutrition New Client Profile Form

Step 1 of 8 - Address Information

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First Name*
Last Name*
Contact E-mail*
Contact Phone Number*
Address
Street Address Address Line 2 City State / Province ZIP / Postal Code Country
Emergency Contact Name
Emergency Contact Phone

Age
Date Of Birth
Gender
- Male
- Female
- Other
Height*
Height (inches)*
Weight (lbs)*
BMI
Waist (inches)*
Hip (inches)*
Neck (inches)*
W / Hip ratio
% Body Fat
Weight at Heaviest
Pounds
Weight at Lightest
Pounds
Blood Type
Are you a smoker?
- Yes
- No
Have you Ever smoked?
- Yes
- No
Date Quit Smoking
Occupation
Stress Level
Activity Level

Describe Your current Exercise Program
List your Limitations to Exercise
How long have you been following this regimen

Are you seeing a physician for any reason? Use comment section to list reasons.
- Yes
- No
Please list reasons for seeing a physician
Are you taking any prescription medications? Use comments section to list medications.
- Yes
- No
Please list prescription medications
Are you taking any supplements? Use comments section to list supplements
- Yes
- No
Please list supplements you are taking

Do you have any health related issues?
- Yes
- No
Please explain:
Do you have any known diseases?
- Yes
- No
Please explain:

Are you a Male over age 45 or female over 55?
- Yes
- No
Has a parent or sibling experienced a heart atttack before age 65?
- Yes
- No
Do you have high blood pressure, diabetes, or thyroid disease, high cholesterol?
- Yes
- No
Please explain:
Do you have any known allergies?
- Yes
- No
- Not sure
Please explain:
Do you have any known eating disorders?
- Yes
- No
Please explain:

What is your largest meal?
Do you Snack during the Day?
- Yes
- No
What type of snacks?
Do you snack after dinner? If so list snacks
What size do you consider your portions to be?
Do you eat when depressed?
- Yes
- No
- Sometimes

Additional Information (medications etc)

Welcome to our Nutritional Guidance: New Client Profile Form page at PersonalTrainerSanDiego.com.

This form is designed to help us better understand your nutritional needs and goals so that we can provide you with personalized guidance and support. Whether you’re looking to improve your diet, lose weight, or simply adopt healthier eating habits, our team is here to help you achieve your goals.

Get Started Today

Ready to take the first step towards a healthier you? Fill out the form to schedule a consultation. Our team will review your information and contact you to schedule a convenient time for your consultation. Together, we’ll develop a personalized nutrition plan that works for you and helps you achieve your health and fitness goals.