STRIDE: Meal Plan Application

Client Profile Questionnaire

Name First Last
Home Phone - (###) - ### ####
Work Phone - (###) - ### ####
Mobile Phone - (###) - ### ####
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email
Emergency Contact
Full Name

Contact number
General Health and Nutrition Questions
Gender Male Female
Date of Birth / MM / DD YYYY
Height
Feet and Inches
Weight
lbs.
Body Fat
%
Explain in detail what type of resistance exercises, cardiovascular or sport activities you perform on average during a seven (7) day period.

Exercise / Activity
Type of Exercise or Activity

Days / Week

Duration
Type of Exercise or Activity

Days / Week

Duration
Type of Exercise or Activity

Days / Week

Duration
Type of Exercise or Activity

Days / Week

Duration
Please list below everything you eat in one twenty-four (24) hour period. Be sure to include snacks and beverages, including water. Also, please indicate approximate amounts.

Eating Habits
Breakfast:

Time

Food / Beverages consumed
Snack:
Time

Food / Beverages consumed
Lunch:
Time

Food / Beverages consumed
Snack:
Time

Food / Beverages consumed
Dinner:
Time

Food / Beverages consumed
Snack:
Time

Food / Beverages consumed
How would you rate the activity level of your profession, or what you do during the day (non-exercise related) Sedentary Moderately Active Active Very Active
What are your goals? Weight Loss Maintain/Improve Eating Habits Gain Weight
What is your goal weight?
lbs.
List your favourite foods:
List foods you dislike:
Which best describes you? Sedentary Adult Exercising Adult Competitive Athlete Growing Teenage Athlete Adult Building Muscle Athlete Restricting Calories
Which of the following statements best describes you? I can eat practically anything I want and I do not gain weight. i find it difficult to gain weight. I can lose or gain weight by adjusting my activity level and eating habits I find it difficult to lose weight. I can gain weight easily and have to watch what I eat.
Check any health and/or medical conditions that apply Heart disease Anemia Hypoglycemia Diabetes Liver Disease Pancreatic disease Lactation Hypertension Other Please specify
Have you ever been on diets or other nutritional programs? Yes No
If yes, what were they?
What were your results?
I AGREE TO ALLOW STRIDE, WEIGHT MANAGEMENT CONSULTANT, TO DESIGN A WEIGHT MANAGEMENT PROGRAM FOR ME TO ENHANCE MY HEALTH AND FITNESS GOALS. I WILL FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY AND I WILL NOT HOLD STRIDE OR ANY ONE RELATED PERSONS OR PARTIES PERSONALLY LIABLE FOR ANY PROBLEMS, ILLNESSES OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY EATING HABITS. I UNDERSTAND THATSTRIDE IS NOT A REGISTERED OR LICENSED DIETITIAN, NOR A MEDICAL PRACTITIONER. THIS WEIGHT MANAGEMENT PROGRAM DOES NOT REPLACE THE EXPERT ADVICE OR MEDICAL TREATMENT OF MY OWN PRIVATE DOCTOR. I HAVE GIVEN STRIDE ALL NECESSARY INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS.
Signature:
Full Name

Date
Do Not Fill This Out

Client Profile Questionnaire

General Health and Nutrition Questions

Exercise / Activity

Eating Habits