F9 Questionnaire - ProtrainerliveProtrainerlive

Profile

First Name

Last Name

DOB(MM_DD_YY)

SEXM F

Address

City

Prov

Postal Code

Tel

Cell/Other

Email

How did you hear about us

Do you have any allergies?YES No

(Please specify)

Do you have any past or present health issues or any issues that are in your family history?
(Please check all that apply to you)

CARDIOVASCULAR DISEASE

Arteriosclerosis

Stroke

Aneurysm

Cholesterol

Varicose Veins

HEART DISEASE

High Blood

Low Blood Pressure

Heart murmur

Angina pectoris

Myocardial Infarction

Rheumatic fever

Cardiac Arrhythmia

Tachycardia

Neurological
Disorder

Epilepsy

Impingemen Syn.

Sciatica

Insomia

Muscular-Skeletal Disorder

Osteoarthritis

Osteoporosis

Rheumatoid arthritis

Tendonitis/Bursitis

Whiplash

Fibromyalgia

Herniated disc

Respiratory Disorder

Asthma

Emphysema

Other (specify)

Endorine Disorder

Diabetes

Hyperthyroidism

Hypothyroidism

HEART DISEASE

Hernia

Anaemia

Chronic fatigue syn.

Ulcers

Allergies

Tumour/cyst

Sickle cell

Migraines

If one or more of the above conditions relate to you, please provide a brief detail
(e.g. surgery/doctor’s recommendation)

Do you have any pain in the following areas?
(If yes, please mark the box that best describes the severity of pain that you feel)

	YES	NO	EXTREME	MODERATE	MILD	LEFT	RIGHT
Toes
Forefoot
Arch
Heel
Ankle
Leg
Knee
Hip
Low
Back
Shoulders
Elbow
Neck
Wrist
Hand
Fingers

Lifestyle Habits / Behaviour

Occupation

Description of work performed

Hours worked per week

Number of days worked per week

Do you find your occupation stressful?YES NO

(Please specify)

What do you do for stress relief?

Do you currently smoke?YES NO

Have you ever smoked? YES NO

How long

Do you drink alcohol? YES NO

How many drinks per week?

Do you drink coffee/tea?YES No

How many cups per week?

How is your sleeping pattern? GOOD AVERAGEPOOR

How many hours do you sleep per night?

How much water do you drink per day?

How much juice do you drink?

Do you juice it yourself? YES No

Do you drink pop?YES No

How much?

Do you use salt?YES No

Which one?

Do you use soy or soy sauce?YES No

Do you use sugar/sweetener?YES No

Which one?

Do you cook with oil?YES No

Which one?

Do you use jams, butter or margarine?YES No

Which one?

Do you use salad dressing and condiments?YES No

Which one?

Do you have digestive problems after eating particular foods? YES No

What do you experience?

Do you consume diary? YES No

How much?

Which types of poultry and meat do you consume regularly What type of fish do you consume?

Which fruit, vegetables nuts and seed do you consume?

FRUITS			NUTS
Apple	Figs	Nectarines	Almond
Apricot	Gooseberry	Olive	Brazil Nut
Avocado	Gourd	Orange	Beechnut
Banana	Grapefruit	Papaya	Cashew
Barberry	Grapes	Passion Fruit	Chestnut
Blackberry	Guava	Pawpaw	Filbert
Boysenberry	Hawthorn	Peach	Hazelnuts
Blueberry	Honeydew	Pear	Macadamia
Caca	Jackfruit	Pineapple	Peanuts
Carrot	Jujube	Plum	Pecans
Cashew Fruit	Kiwi fruit	Pomegranate	Pine nuts
Cherry	Kumquat	Raspberry	Pistachio
Coconut	Lemon	Rhubarb	Walnut
Crabapple	Lime	Strawberry
Cranberry	Lychee	Sweet Lime
Currant	Mandarin	Tangerine
Custard Apple	Mango	Tomato
Dates	Melon	Watermelon
Elderberry	Mulberry

VEGETABLES			SEEDS
Alfalfa	Cucumber	Parsley	Chia
Artichoke	Eggplant	Peppers	Flax Seed
Asparagus		Peas	Pumpkin Seed
Avocado	Ginger	Potatoes	Sesame Seed
Beets	Green Bananas	Pumpkin	Sunflower
Broccoli	Horseradish	Radish
Bok Choy	Kale	Rutabaga
Brussels Sprouts	Kohlrabi	Spinach
Cabbage	Lettuce	Sweet Potato
Carrots	Lima Beans	Tomatoes
Cauliflower	Mushrooms	Turnip
Celery	Mustard Greens	Watercress
Chard	Okra	Yams
Chili Peppers	Onions
Corn

Are there food choices not listed above that you eat regularly?

Do you eat canned food? YES no

NUTRITIONAL BACKGROUND

Which of the following meals do you eat and what do you usually eat daily?

BreakfastYES NO

Mid morning snackYES NO

LunchYES NO

Mid afternoon snackYES NO

DinnerYES NO

Evening snackYES NO

List your favourite junk foods

PHYSICAL ACTIVITY

Are you involved in any physical activity?YES NO

Please list

How would you classify your activity level?Low IntermediateHighVery High

What is your favourite physical activity?

Do you experience the following symptoms prior to, during or after physical activity?

Can the above pain be describe as a Dull ache Sharp StabNumbness/tingling

Other

PERSONAL GOALS

Presently what are your ultimate fitness goals?

What would you like to focus on? (Check all that apply)

Fitness	Nutrition	Athletics	Body building
Weight loss	Strength	Shaping	Other

PERSONAL TRAINING

Have you ever worked with a personal trainer?

for what purpose?

When?

How long?

Are you currently happy with your physical state?YESNO

What do you like about your physique?

What do you dislike about your physique?

What do you need a personal trainer to help you with?

Have you been treated by a chiropractor/physical therapist?YESNO

When?

Why?

Are you currently taking any dietary supplements?YESNO

Which one

Would you like dietary supplements to be a part of your training program?YESNO

Are there any physical reasons why you should not follow any exercise program?YESNO

What?

Muscle cramps	Dizziness	Neck/back pain	Swelling of joints
Grinding joints-crepitus	Shortness of breath	Chest pain	Headaches
Coughing/nausea	Irregular bowel movements

F9 Nutrition

Profile

Medical History

CARDIOVASCULAR DISEASE

HEART DISEASE

Neurological
Disorder

Muscular-Skeletal Disorder

Respiratory Disorder

Endorine Disorder

HEART DISEASE

Lifestyle Habits / Behaviour

NUTRITIONAL BACKGROUND

PHYSICAL ACTIVITY

PERSONAL GOALS

PERSONAL TRAINING

F9 Nutrition

Profile

Medical History

CARDIOVASCULAR DISEASE

HEART DISEASE

Neurological Disorder

Muscular-Skeletal Disorder

Respiratory Disorder

Endorine Disorder

HEART DISEASE

Lifestyle Habits / Behaviour

NUTRITIONAL BACKGROUND

PHYSICAL ACTIVITY

PERSONAL GOALS

PERSONAL TRAINING

Neurological
Disorder