Initial Client Profile Form: Contact Information
First Name:
Last Name:
Mailing Address:
Email Address:
Home Phone Number: () - -
Personal Information
Occupation:
Age:
Height:
Birthday:
Gender:
Current Body Weight (if known):
Goal Date:
Your age the last time at Goal Weight:
How Did You Hear About Us?
Medical and Physical Status
Indicate relevant conditions
Diabetes Glycemic Disorder (Hypo or Hyper) Heart Condition
Anemia Cancer Thyroid Dysfunction
IBS Cystic Fibrosis Ulcers
Heartburn High Blood Pressure Cancer
HIV/AIDS Hepatitis Depression
Anorexia/Bulimia Pregnant Fluid Retention
Multiple Sclerosis Kidney or Liver Disease Allergies
Please indicate specific condition details and/or medications:
Nutrition Status
Are you taking any supplements or health products? Yes No
If yes, which product and how much do you take:
How many glasses of the following do you consume weekly?
Beer:
Wine:
Spirits:
Milk:
Juice:
Soft drinks:
Including snacks, how many times do you eat each day?
What is your favorite food(s)?
Do you eat all your vegetables? Yes No
List any major food dislikes:
What and how much do you put in your coffee, if any?
How many glasses of water do you drink each day?
How often do you eat out weekly?
Do you snack at night? Yes No
If so, what do you snack on?
Weight Loss History
Will family and friends be encouraging your weight loss efforts? Yes No
Does your family have a history of weight issues? Yes No
Have you ever been on a diet or nutrition program before? Yes No
If yes, which programs and what were some of the positives and negatives?
How many weight loss attempts have you made?
How many attempts were a success?
Activity Level
Please indicate your current exercise habits, if any:
Walking Biking Jogging
Weight Lifting Sprinting Sports
How many days a week?
How many hours a day?
Which of the following best describes you:
Sedentary (very little exercise, but might take an occasional walk)
Light Activity (you participate in a sports event once or twice a week)
Moderate Activity (you train three to five days a week, doing weights and some cardio
High Activity (you are heavily involved sport, cardio, or resistance training 6 days a week)
Elite Athlete (you workout intensely twice a day)
BE HONEST....HEHE
What have you ate so far today, do not leave anything out.
If you have made any weight loss attempts in the past and were unable to keep the weight off what would you say is the number one reason why you were unable to maintain your weight or reach your weight loss goal?
Nutrition Analysis Questionnaire Needs AttentionFairGoodGreat
Amount of energy every day 1 2 3 4
I enjoy eating a diet with lots of variety 1 2 3 4
I eat at least 3 to 5 servings of vegetables daily 1 2 3 4
I eat a variety of vegetables (lots of different colors) 1 2 3 4
I eat at least 3 to 5 servings of fruit each day 1 2 3 4
I eat a variety of fruit 1 2 3 4
I eat 5 to 12 servings of grain products each day 1 2 3 4
I attempt to eat whole grain products and avoid refined (white flour) grain products 1 2 3 4
I am careful to eat appropriate serving sizes of grain products 1 2 3 4
I consume 2 to 4 servings of milk products daily 1 2 3 4
I avoid milk products that are high in fat 1 2 3 4
I eat 2 to 3 servings of meat and alternatives each day 1 2 3 4
I have a reduced consumption of red meat 1 2 3 4
I eat beans and legumes 1 2 3 4
I eat seafood/fish at least once a week 1 2 3 4
I chose healthy snacks and avoid snacks that have low nutritional value 1 2 3 4
I drink at least 8 to 12 glasses of water daily 1 2 3 4
I take supplements to balance my diet 1 2 3 4
I read labels and I am careful about food I serve 1 2 3 4
My body weight is..? 1 2 3 4
Amount of fat vs. lean muscle 1 2 3 4
I avoid eating fast food 1 2 3 4
I am pleased with my physical appearance 1 2 3 4
Generally my diet is well-balanced 1 2 3 4
Overall assessment of health / well being 1 2 3 4
What type of weight loss coach do you need?
The Terminator
  • ZERO excuses, no room for error
  • You will be mentally beat into submission
  • Name calling, very likely
  • If caught in public not following the plan, public humiliation will ensue "spying is very probable" Be afraid...be VERY afraid
The Drill Sergeant
  • Excuses are punishable
  • Goals will be mandatory
  • Accountability - a MUST
The Super Nanny
  • The firm yet caring and understanding coach
  • Will not accept excuses but will not shame you into oblivion
  • Relationship can be bitter at first but turns into a long term friendship
The Push Over
  • Weight Loss coach may sit and eat cookies with you
  • The person who will understand your excuses and say, "it's okay"
  • Success - not likely with this weight loss coach