Nutrition Questionnaire

First Name Last Name

Address

Address 2

City State Zip Code

Phone (home) Phone (work)

E-mail

Personal Information

Height (example 5'8") Weight Age Male(M) / Female(F)

Medical History

Allergies Abnormal Sleeping Patterns Arthritis, Bursitis Back Pain (low, mid, neck) Cancer Chest Pain Diabetes Elevated Cholesterol Embolism (Blood Clot) Heart Disease (Heart Attach, Murmur) Head Aches/Fainting Joint Injuries Liver Disease Lung or Respiratory Disease Muscle Cramps/Spasms Operations/Surgeries Pregnancy Stroke

If you answered yes to any questions, please explain.

Are you currently taking any medications?

Lifestyle

How do you characterize your lifestyle?

How active do you consider your everyday lifestyle?

Are you presently involved in an exercise or sports program? Yes No

Explain?

Please indicate your goals for this nutrition program. (Check all that apply)

Please describe yourself.

Give us an example of your daily food intake.

Please provide any additional information to help us with your nutrition program. (favorite foods, least favorite foods, etc.)

Anyone starting a nutrition program should always consult with their physician. By submitting this information you agree to release Elite Strength from any liability.