Date:
Name:
Age:
Weight:
Height:
Email:
Phone#:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
What is the target weight you want to achieve?
In what period of time?
Why do you want to start exercising?
Do you have any injuries to prevent you from exercising on a routine basis?
When was the last time you had a pyhsical?
Do you have a doctors release to start exercising?
What medication are you taking?
Have you ever exercised before?
How often?
Do you exercise now?
How often?
What time of the day do you exercise?
If so , what percent cardio and what percent weight lifting?
Have you ever had a C-section?
Are you willing and able to make a change in your weekly routine?
Do you want to change your eating patterns?
Do you have family or spousal support to change your weekly routine?
How many hours per week can you dedicate to working out?
How many times per day do have a full meal?
How many times per day do snack?
How many times a week do you eat at a resturant?
How many times a week do you cook a well balanced diet?
How many hours per week do you spend preparing your meals for the week?
Do you own a food scale?
Do you have any special events in the future you would like to prepare for?
How many hours of sleep do you get each night?
How often do you drink alcohol and how much?
Do you take any supplements such as: vitamins, amino acids, protien powder?
How do you rank your health on scale of 1 to 10? 10 is pefect
What do you want to change the most about yourself?
www.bodydesignbypaula.com
28
what are your typical work hours?
29
Please list all the foods you LIKE by category:
Vegetables:
Fruits:
Meats:
Dairy:
Legumes: beans, seeds, nuts, etc
Grains: Breads, bagels pastry etc.
30
Please list all the foods you DISLIKE by category:
Vegetables:
Fruits:
Meats:
Dairy:
Legumes: beans, seeds, nuts, etc
Grains: Breads, bagels pastry etc.
www.bodydesignbypaula.com
31
Please list your typical foods and AMOUNTS you eat throughout the week per meal
Breakfast
Lunch
Dinner
Snack
Drinks
Condiments
www.bodydesignbypaula.com