Gunelson Fitness & Nutrition

Fitness & Nutrition Intake Form

Name:

Email:

Phone:

Address:

Age:

Height:

Weight:

How many times a day do you eat?

Do you eat breakfast? If so, what do you typically eat for breakfast?

Do you eat lunch? If so, what do you typically eat for lunch?

Do you eat dinner? If so, what do you typically eat for dinner?

Do you snack? If so, when and what do you typically snack on?

How much water do you drink a day?

Which of the following do you drink and how much? Pop, Coffee, Alcohol?

Do you have food sensitivities?

Do you have any allergies?

Are you on any medications? If so, for what?

Do you take any supplements (ex: vitamins, protein powders)

What is the quality of your sleep? (how many hours a night do you believe you sleep?)

Do you currently exercise? If yes, how often do you exercise?

How long and what type of exercise do you do if any? (ex: strength training, yoga, cardio)

How long has it been since you have done any strength training?

How long has it been since you have done any cardio?

Are you currently in any active sports? If no, did you participate in active sports within the last 7 years?

Have you ever worked with a personal trainer?

How was your experience with a personal trainer?

What equipment do you have available to you, either in your home or nearby (gym/club etc)?

Which program(s) are you interested in, Nutritional Plan, Fitness Plan, Both or Personal Training?

What is your Goal?

Personalized Fitness Plans

Personalized Nutrition Plans