Date:

First Name (required):

Last Name (required):

Age:

Sex:

Address:


City:

State:

Zip:

Daytime or work phone (required):

Evening or home phone (required):

Best time to contact:

Fax:

Email address (required):


Do you want to be contacted by phone to review your questionnaire and discuss a customized nutritional supplement program?
Yes  No

Please give a brief description of the health and fitness goals you are trying to improve or achieve.

ENERGY

1. How are your energy levels throughout the day? HighModerateLow
2. Do you need more energy or stamina during your workouts?
   Yes  No
   
3. Do you get sleepy or lethargic after eating?
   Yes  No
   

NUTRITION

1. How many meals do you eat per day? onetwothreefourfivesix or more
2. Do you skip meals? Yes  No
   If so, which meals do you skip on most days? breakfastlunchdinner
3. What time do you eat breakfast? AM PM
4. What time do you eat lunch? AM PM
5. What time do you eat dinner? AM PM
6. Do you eat snacks? Yes  No
   If so, when do you snack? Check all that apply.
   Between breakfast & lunch Between lunch & dinner Between dinner & bedtime Middle of the night
7. How many times per week do you eat fatty foods, fast foods or fried foods? neveroncetwicethree timesfour timesfive times or more
8. Do you crave sweets or carbohydrates?
   Yes  No
9. How many servings of fruits and vegetables do you eat daily? A serving equals 1/2 cup of cooked or raw vegetables; 1 cup of leafy vegetables; 1/2 cup of fresh, frozen or cooked fruit or 1/4 cup of dried fruit. noneonetwothreefourfive or more
10. How many cups of coffee, tea, soda, or other caffeinated beverages do you consume each day? noneonetwothreefour or more
11. Are you over sensitive to caffeine?
    Yes  No
12. Are you allergic to seafood?
    Yes  No
13. Are you allergic to any soy products?
    Yes  No
14. Are you currently dieting?
    Yes  No
15. Are you currently or have you ever taken any product to enhance weight loss?
    Yes  No
16. Do you have problems swallowing or taking pills or vitamins?
    Yes  No

SUPPLEMENTATION

1. Do you currently take any over-the-counter nutritional supplements? Yes  No
   If so, indicated which ones you are currently taking: Multi-vitaminVitamin CAntioxidantsEssential fatty acidsCalciumIronOther
2. Are you currently taking a protein supplement (shakes or bars) to round out your diet?
   Yes  No
3. Are you currently taking any type of creatine supplement?
   Yes  No
4. List any other nutritional supplements that you are currently taking below:

    

   DIGESTION

   1. How is your digestion? Indicate the number of daily bowel movements you have:
      Missing days - Irregularonce - Borderline Irregulartwice - Average3 to 6 times - Regular
   2. Do you suffer from indigestion or have any gastro-intestinal problems?
      Yes  No

   FITNESS

   1. Are you currently exercising?
      Yes  No
   2. What time of day do you usually train?
      AM PM
   3. How many times a week are you doing some type of cardiovascular fitness (walking, jogging, running exercising? noneoncetwicethree timesfour timesfive times or more
   4. Check below the types of cardiovascular fitness you currently participate in:
      Walking Jogging Running Treadmill
      Elliptical training Stationary bike Recumbent bike
      Bicycle Aerobics class Other
   5. Are you currently weight training as a part of your exercise program?
      Yes  No
   6. What time do you exercise each day? morningnoonafternoonevening
   7. Where do you currently exercise? gympersonal training studiohomeofficeother
   8. If home or gym, explain what type of equipment you are using. NoneFree WeightsMachinesOther
   9. Do you currently suffer from any joint pain from a previous injury (tendon, cartilage, etc.) that prevents you from being as active as you would like?
      Yes  No
   10. Do you have problems with muscle cramping during exercise or workouts?
       Yes  No
   11. Do you wish to have faster recuperation following exercise?
       Yes  No
   12. Is there any reason at all (health or personal) that would limit or prevent you from exercising?
       Yes  No

   REST

   1. How many hours of sleep do you get on an average night? less than fourfivesixseveneightnine or more
   2. What time do you generally go to bed? AM PM
   3. What time do you generally wake up? AM PM
   4. Do you suffer from insomnia or have trouble sleeping?
      Yes  No

   GENERAL HEALTH

   Height:
   
   Current weight:
   
   Weight 1 year ago:
   

   1. How much weight would you like to lose? 0-9 lbs10-20 lbs20-30 lbs30-40 lbs40-50 lbs50-100 lbs100+ lbsdon't need to loose
   2. How much weight would you like to gain? 0-9 lbs10-20 lbs20-30 lbs30-40 lbs40+ lbsdon't need to gain
   3. Do you consider yourself to have a high stress level?
      Yes  No
   4. Is your total cholesterol greater than 200? yesnonot sure
   5. Do you have weak bones?
      Yes  No
   6. Do you desire increased anti-oxidant and/or anti-aging protection?
      Yes  No
   7. Do you smoke? Yes  No
      If yes, how many packs per day? less than oneonetwothree or more
   8. Do you drink alcohol? Yes  No
      If yes, how many drinks per week? 1-34-66-1010 or more

   WOMEN'S HEALTH

   1. Are you post-menopausal? Yes  No
      
   2. Do you suffer from hot flashes? Yes  No
      
   3. Are you pregnant or lactating? Yes  No
      

   MEDICAL INFORMATION

   1. Do you have any of the following conditions? Check all that apply
      Diabetes Hyperthyroidism Hypothyroidism High blood pressure
      Heart problems Coronary artery disease
   2. Do you suffer from a degenerative disease (osteoarthritis, osteoporosis, etc.)?
      Yes  No
   3. Do you suffer from fibromyalgia or overall aches and pains?
      Yes  No
   4. Do you or your children suffer from attention deficit disorder?
      Yes  No
   5. Do you suffer from anxiety?
      Yes  No
   6. Do you ever feel faint or dizzy?
      Yes  No
   7. Are you currently taking any prescribed medication? Yes  No
   8. Have you had surgery in the last year? Yes  No

   Thank you for taking the time to fill out this questionnaire. If you checked the box above allowing us to contact you, we will call or e-mail you within 24-48 hours to discuss your questionnaire and a customized nutritional supplementation program built for you.
   
   By clicking on submit, I certify that I am over the age of 18 and have read and fully understand the contents of our Disclaimer and agree to its terms and conditions in full.