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Print and fill out and send it along with your payment (do not send cash) toYOUR GYM 117 South Broad Street Grove City, pa.16127 or e-mail the form to email@example.com
The Trainers Edge Questionnaire
HOME ADDRESS ___________________________________________________________________________
City________________________________________ State ____________________ ZIP ________________
PHONE: (home)________________________________ (work) _____________________________________
AGE_____ DATE OF BIRTH ______________ SEX:____ (M or F) HEIGHT:___________ (in inches)
CURRENT WEIGHT:_____________ (pounds) DESIRED WEIGHT:____________________ (pounds)
CURRENT BODYFAT%: _____________ DESIRED BODYFAT%: _________________________
PRIMARY Bodyweight Priority (check one or both): _____ Fat Loss Muscle Gain
PRIMARY TRAINING AND NUTRITION OBJECTIVE
(check one or more):
______Fat Loss ______Fitness (General)
______Bodybuilding (Recreational) ______Strength (Recreational
______Bodybuilding (Competition) ______Aerobic Sport(s) (Specify)
______Aerobics (Recreational) ______Other Sport(s) (Specify)
Specify Sport(s) or other objectives (e.g., body parts, cross-training) not listed above
HOW MANY MONTHS WILL IT TAKE YOU TO ACHIEVE YOUR GOAL?
(6 weeks minimum for fat loss; 2 months minimum for fitness, sports or bodybuilding objectives)
2 3 4 5 6 7 8 9 10 11 12
Girth Measurements (inches) Caliper Measurements (mm)
Upper Arm Girth Bicep Supraillac _______
Forearm Girth Tricep _______ Chest _______
Waist Girth Subscapular _______ Abdominal _______
Hip Girth Thigh _______
Thigh Girth Calf _______
Wrist Girth Kidney _
How would you rate your overall EXERCISE
. Sedentary = Those who have little or no history of training or dieting since their school days.
. Beginners = Had been working out on and off, but not seriously.
. Intermediates = Those who were thoroughly familiar with weight training exercises, and had exercised very
. Upper-Intermediates = Bodybuilders, athletes and fitness-oriented people who were in shape and who had
been highly committed to their training and nutrition.
. Advanced = Accomplished collegiate, amateur or professional bodybuilders, athletes and fitness-oriented
people who had been training seriously for a substantial period of time, are thoroughly familiar with training
equipment and sound nutritional practice, and who used to take training and nutrition very seriously.
How would you assess your present PHYSICAL
. Never Exercise = Those who have little or no recent history of training or dieting.
. Beginner = Those just getting into training and dieting within the past year or two, who workout around 3
. Fair = Those who have worked out at least a year or two, are very familiar with weight training exercises, are
serious about their training and nutrition and exercise 3-5 times weekly.
. Good = Bodybuilders, athletes and fitness-oriented people who are already in pretty good shape and who are
ready to "make the commitment" to amplify their training efforts to the maximum.
. Excellent = Accomplished collegiate, amateur or professional bodybuilders, athletes and fitness-oriented
people who have been training seriously for a substantial period of time, are thoroughly familiar with training
equipment and sound nutritional practice, and who takes training very seriously.
. Pre-Competition or Pre-Season = Professional, amateur or collegiate athletes ready to enter a competition
(contest or season). Allow 12-16 weeks for this preparatory training cycle.
HOW OFTEN WILL YOU WORK OUT PER WEEK?
Non-Athlete Beginners and Intermediates:
1 2 3 4 5 6 7 once or I’ll let The Trainers Edge
minimum two times decide for me,
recommended per day as as I have a lot of
scheduled free time (or will MAKE
Athletes and Advanced Fitness Enthusiasts:
3 4 5 6 7 twice or I’ll let The Trainers Edge
minimum three times decide for me,
recommended per day as as I have a lot of
scheduled free time (or will MAKE
WHAT TIME(S) OF DAY WILL YOU WORK OUT?
Please indicate the best days and times for your workouts. (up to 3 workouts daily)
1st Workout 2nd Workout 3rd Workout Wake-up Bedtime
. Sunday ___________ am. _________ pm.
. Monday ___________ am. _________ pm.
. Tuesday ___________ am. _________ pm.
. Wednesday ___________ am. _________ pm.
. Thursday ___________ am. _________ pm.
. Friday ___________ am. _________ pm.
. Saturday ___________ am. _________ pm.
Please Estimate your DAILY ACTIVITY LEVEL.
For each 3-hour block of time listed below, key in your average activity level for that time period. Note that
several of the time blocks will correspond to your sleep time. Estimate your average activity level where a combination of activities are engaged in or if your activity isn't precisely described.
This information is essential to calculate the caloric value of each of your daily meals.
Midnight until 3 a.m._____________% . Noon until 3 p.m.______________%
. 3 a.m until 6 a.m._______________% . 3 p.m. until 6 p.m._____________%
. 6 a.m until 9 a.m._______________% . 6 p.m. until 9 p.m._____________%
. 9 a.m. until Noon_______________% . 9 p.m. until Midnight___________%
How many hours of sleep are you getting? ________ hours
Energy Expenditure Guide
minus 20% = Sleeping
0% = Resting: Lying down totally relaxed but not sleeping (your “basal metabolic rate”)
25% = Very Light: Sitting, studying, talking, little walking or other activities.
50% = Light: Typing, teaching, lab/shop work, some walking.
75% = Moderate: Walking, jogging, gardening type job.
100% = Heavy: Heavy manual labor such as digging, tree felling, climbing.
125% = Exceptionally Heavy: Fitness-oriented weight training, aerobic dance, cycling or similar
150% = Sports: Vigorous sports competition such as football, racquetball, tennis or other
175% = All-Out Training: Extremely high intensity weight training with little rest between sets or exercises.
200% = Extended Maximum Effort: Extremely high intensity and high duration sports
competition or training such as triathlon, cross-country skiing or marathon.
Select foods you enjoy eating on the 3 Food Selection Sheets. Be honest with yourself!
Do NOT select the foods you dislike or are not likely to buy.
Use a check mark for foods to be chosen for each of the Meal Categories.
P Anchovie Ps Balance bar
P Bison Ps Clif Bar
P Boca Burger meatless no fat Ps Fury bar
P Cheese Stick non-fat Ps GeniSoy Protein Bar
P CHEESE,Ched.n-ft Ps Labrada Lean Body
P CHEESE,HlthyC.no-fat Ps Labrada Lean Body Bar
P CHEESE,Kraft no-fat Ps Medsport Whey Protein
P Chicken - oz Ps Met-Rx Keto Pro
P CHICKEN BREAST Ps Met-Rx Pro 50
P Chicken Breast Fat Free Ps Met-Rx Protein Plus
P CHICKEN CAN'D Ps Met-Rx Source One
P CLAMS,steamed Ps Myoplex Lite
P COOKIE,High Protein Ps Nytro Pro
P COTTAGE Cheese Ps Parillo Energy Bar
P CottageCheesenon-fat Ps Pr Ironman Bar
P CRAB,alaskan Ps Protein Meal Replacement Drink
P CRAB,blue Ps Protein Powder
P EGG,whites only Ps Ultimate Lo Carb Bar
P EGG,WHOLE LG. Ps Worldwide Pure Protein Bar
P FLANK STEAK
P Ground Round Steak
P HAM, very lean *Add Personal Choices if desired.
P Hot Dog Fat-Free
P MILK,NON-FAT P ALMOND BUTTER
P MUSSELS,steamed P ALMONDS
P Ricotta Cheese P AVOCADO,Florida
P ROUND STEAK P FAKIN'BACON bits
P Salmon Steak P FLAX OIL
P SARDINES /TOM. P M. C. T. (LIQUID)
P SCALLOPS P MAYONNAISEhellmn's
P SHRIMP P PARMESAN,cheese
P SWORDFISH P PINE NUT,PIGNOL
P Tempeh P PROM.NOFATBUT.
P TOFU P PUMPKIN SEED
P TOFU, Lite P SESAME BUTTER
P TUNA,CANNED P SESAME SEEDS
P TURKEY BREAST P SOUR CREAM
P Turkey Breast Fat Free P SUNFLOWER BUTTR
P Turkey Franks (Sheltons) P SUNFLOWERseeds
P TURKEY,sausage P SWISS CHEESE
SELECT THE FOODS YOU WILL EAT REGULARLY.
Protein Foods Protein Meal Replacement Foods
Healthy Fat Foods
C1 ALFALFA SPROUT C2 APPLES'CE unsweet
C1 ARTICHOKE C2 BEANS, cooked dry
C1 ASPARAGUS C2 BLUEBERRIES
C1 BABY P PODS FZ C2 BLACKBERRIES
C1 BELLpeppr,green C2 CANTALOUPE
C1 BELLpeppr,red C2 CAROB,chips
C1 BELLpeppr,yellow C2 CherriesDark Sweet
C1 BROCCOLI C2 Classico Tomato Sauce
C1 Broccoli - oz C2 FIG, raw
C1 BRUSSELS SPROUTS C2 GRAPEFRUIT
C1 CABBAGE,green C2 HONEYDEW,melon
C1 CABBAGE,red C2 JELLO,sugar free
C1 CAULIFLOWER C2 KIWI, FRUIT
C1 CELERY C2 MANGO
C1 Cinnamon,ground C2 MIXED VEG.frozen
C1 COFFEE,brewed C2 MUSTARD
C1 COLLARD,GREEN C2 ONION, chopped
C1 CUCUMBER C2 ORANGE
C1 EGGPLANT C2 PAPAYA,raw
C1 GARLIC,raw C2 PARMESAN,cheese
C1 GREEN BEAN C2 PEACH
C1 HORSERADISH C2 PEAR
C1 JALAPENO,pepper C2 PINEAPPLE
C1 KALE C2 PLUM
C1 LEMON,fresh C2 PUDDING,jellosugfree
C1 LETTUCE,rom,bibb C2 RASBERRIES
C1 LIME,fresh C2 RYVITA,Cracker
C1 MUSHROOMS,raw C2 Steamed vegetables
C1 Non-Fat Mayonnaise C2 STRWBERRY,fzn
C1 PARSLEY C2 SQUASH,winter
C1 PICKLE, dill C2 SWEET POTATO
C1 RADISH,raw C2 WASA,cracker
C1 SALAD IN A BAG C2 YOGURT NO FAT
C1 TOMATO SAUCE
Carbohydrates Class 1 Carbohydrates Class 2
C3 ALPEN cereal
C3 Bagel, Thomas multi-grain
C3 Chocolate chips
C3 Cookie, Barbara's Double Chocolate
C3 Cheese Waffies
C3 CORN, CRT, BNS
C3 Familia Choc Granola
C3 Granola Fiber Bar
C3 Kashi, chocolate pillows cereal
C3 Kashi, to good friends cereal
C3 MUFFIN, non-fat
C3 New York Flatbreads
C3 Pretzel, Harry's Everything
C3 Pretzel, Peanut Butter
C3 PUFFED KAMUT
C3 PUFFED RICE CL
C3 RICE CAKES
C3 Rice Dream, Frozen Dessert
C3 Snackwell,cookies peanut butter
C3 SOY MILK
C3 SUNFLOWER BREAD
C3 TEMPEH, 3 GRAIN
C3 Tofutti, Frozen Dessert
C3 TOMATO CATSUP
C3 Waffle, Frozen Van's
C3 Steak Sauce
Carbohydrates Class 3
CLIENT'S MEDICAL HISTORY:
Have you experienced any of the following?
Y N Heart attack, coronary bypass or other coronary surgery?
Y N Chest discomfort (especially with exertion)?
Y N High blood pressure?
Y N Extra, skipped or rapid heart beats/palpitations?
Y N Heart murmurs, clicks, or unusual cardiac findings?
Y N Rheumatic fever?
Y N Ankle swelling?
Y N Peripheral vascular disease?
Y N Phlebitis, emboli?
Y N Unusual shortness of breath?
Y N Light headedness or fainting?
Y N Pulmonary disease (e.g., asthma, emphysemia and bronchitis)?
Y N Abnormal blood lipids (cholesterol, triglycerides)?
Y N Stroke?
Y N Recent illness, hospitalization or surgical procedure within the past four months?
Y N Medications of any kind? (if yes, list all on back)
Y N Diabetes or other metabolic disorders?
Y N Are you pregnant now?
Y N Is there any reason your physician would object to your dieting?
Y N Is there a history of heart disease in your family?
Y N Is there any reason your physician would object to your exercising?
I, the undersigned, have read, understand, and have answered the above health/medical survey questions fully
and truthfully. I have consulted with my personal physician regarding my medical fitness to engage in strenuous
exercise and a nutritional support program. I do hereby intend to be legally bound for myself and waive release of
any and all rights and claims for damages as a client / patient, that I may have against Natural Fitness Concepts,
Inc., The Trainers Edge and the Fitness Trainer / Physician administering this instrument for any and all injuries
suffered while following the training and/or nutrition program provided to me.
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