THE FITNESS GURU
Congratulations!
You have just taken the first step toward achieving your personal fitness goals. The next step is to complete this health, fitness and diet questionnaire as accurately as possible. When finished press submit. Thank-you!

Questionnaire

PERSONAL STATISTICS

Name:

Gender: Male Female

Age:

Weight (in pounds):

Height:

Measurements in inches:

Waist:(measure across navel)

Hips:

Neck:



MEDICAL INFORMATION
Do you have heart disease, angina, or irregular heartbeats? Yes No
If Yes please explain:
Do you have any physical limitations, resrtictions, or disabilities?:Yes No

If Yes please explain:
Do you have high blood preasure?:YesNo

Do you have high cholesterol?:YesNo

Do you have Diabetes?:YesNo

Are you on any medication?:YesNo

If Yes please list all medications:
Are you pregnant?YesNo

Do you have any other medical condition that I should know about?



EXERCISE INFORMATION

Do you have access to any of the following: (Check all that aply:)
Gym or Fitness Center
Aerobic classes or video tape
Treadmill
Stationary Bike
Swimming pool
Walking or Biking trail
Weight lifting equipment
Other (explain):



NUTRITION INFORMATION

Are you allergic to any foods? Yes No
If yes, explain:
What foods do you absolutely hate, and will not eat?
What are your favorite foods?
Do you drink coffee or tea?
Yes No
How many soft drinks do you drink per week?
How many servings of fruit juice do you drink per week?
Do you drink alcoholic beverages, and if so, what type and how many per week?
Check below all that are acceptable in your meal plan:
Meat
Poultry
Eggs
Seafood
Dairy products



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