The following multiple-choice questionnaire
is geared towards obtaining lifestyle
information from you to be able to create
the best possible program for you. Please
choose the answers that best describe
your current exercise and dietary habits.
You may choose more than one answer.
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1. How
would you describe your energy level
overall?
low
high
fluctuates with radical highs and lows
medium except for a mid-afternoon lull
satisfactory most of the time
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2. How
many hours of sleep do you get per day?
under 6
6-8 hours
8 hours plus
can range from under 6 to over 8 hours
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3. How
much pure water do you drink in the
day?
rarely drink water
1-5 eight ounce glasses daily
6-10 eight ounce glasses daily
10 eight ounce glasses plus
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4. What
other fluids do you drink?
coffee, tea and other beverages containing
caffine
regular sodas and other sugared drinks
(Coke, Sprite, Snapple)
sports drinks (Carbo Power, Gatorade)
alcohol
milk and/or juice
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5. What
is your usual meal pattern?
breakfast, lunch, dinner with snacks
breakfast, lunch, dinner, no snacks
no breakfast, lunch, dinner, occasional
random snacking
4-6 meals throughout the day (like bodybuilders)
no usual pattern
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6. What
do you flavor your food with?
butter, margarine, gravies or other animal fats
unsaturated oils like olive oil, corn oil, etc…
fat free condiments like mustard, tabasco sauce, etc..
sweet flavors like jam, honey, or sugar
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7. Do
you smoke?
no
heavy smoker
occasional cigarette or cigar
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8. Are
you using any drugs or prescription
medications currently?
No, I do not use any drugs or perscription medications currently
medication for high cholesterol or blood pressure
recreational drugs like marijuana, cocaine,ecstasy
steroids, growth hormone, or any other bodybuilder drug
pain medication (not over the counter)
Other (please enter below)
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9. How
much alcohol do you drink per week?
I do not drink
Very rare that I drink
1-3 drinks per week
4-8 drinks per week
daily, and more than 8 drinks per week
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10. What
kind of supplements do you take on a
regular basis?
I do not take supplements regularly
a multi-vitamin & mineral supplement
aminos acids
creatine monohydrate
pro-hormones (DHEA, Andro,..)
others. Please enter below
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11. How
many times per week do you train with
weights?
I do not train with weights
I have trained in the past but I am
not using weights currently
2-3 times per week
4-5 times per week
6-7 times per week
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12. Please describe your weight training
program.
For example: a 3-Day split.
Day 1: Chest, Shoulders, Triceps,
Day 2: Quadriceps, Calves, & Hamstrings,
Day 3: Back, Biceps, Abdominals. Reps.:
8-12, Sets per body part: Lg. Muscle
groups: 10-12 sets Sm. Muscle groups:
6-8 sets.
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13. How many
cardio/aerobic sessions do you do per week?
I don’t do aerobic exercise.
1-2 times per week
3-4 times per week
5-7 times per week
more than 7 times per week
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14. What is
the typical duration of each aerobic session?
15-25 minutes
30-45 minutes
50-60 minutes
1 hour or more in most sessions
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15. What kind
of exercise do you do on a weekly basis?
outdoor activities (hiking, running, bicycling,
etc…)
gym aerobic equipment (treadmill, stairmaster,
stationary bike etc…)
recreational sports (tennis, basketball, softball,
etc…)
weight training
aquatics (aqua fitness classes, swimming,
surfing, etc…) Please explain :
Other (please enter below)
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16. What is
your primary fitness goal?
weight loss & healthy weight management
change body composition (reduce body fat &
increase muscle)
improve health
increase athletic performance.
get in "contest shape" for either
a fitness or bodybuilding show
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17. Do you have any particular muscle groups
that you wish to build?
Please explain.
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