Standard Gentlemen

Learn to Eat a Balanced Diet
Learn to Balance Activity and Diet
Improve Overall Health
Reduce Stress
Feel Better

Maintain a Healthy Weight
Decrease Body Fat
Increase Flexibility
Increase Endurance
Tone Muscles

Build Muscle Mass
Increase Strength & Power
Improve Speed & Agility
Improve Athletic Performance
Other

Lack of Motivation
Hitting a Plateau
Money

Time
Self-Conscious
Lack of Results

Lack of Equipment
Not Knowing Where to Start
Other

Seeing Results
Accountability

Having Fun
Feeling Better

Praise/Rewards
Other

What is your occupation? Does your job require travel? Yes No

What is the physical activity level of your job? Sedentary Active Demanding

Does your job require extended periods of repetitive movements? Yes No

Do you smoke? Yes No How many glasses of alcohol do you drink per week? 0 1-2 3-5 6-9 10 or more

Rate your level of stress for each of these daily stressors from 1 (extremely low) to 10 (extremely high):

Work 0 1 2 3 4 5 6 7 8 9 10 Family 0 1 2 3 4 5 6 7 8 9 10 Social 0 1 2 3 4 5 6 7 8 9 10 Financial 0 1 2 3 4 5 6 7 8 9 10 Health 0 1 2 3 4 5 6 7 8 9 10 Other 0 1 2 3 4 5 6 7 8 9 10

How many hours do you typically sleep at night? 4-5 5-6 6-7 7-8 8-9 9-10

Do you feel that you get enough sleep? Yes No

Please list any medications and/or medical conditions:

Are you currently physically active? Yes No

If yes, please describe:

Minutes of cardiovascular activity
Times per week
Minutes of strength or resistance training
Times per week
Minutes of flexibility training
Times per week

Realistically, how many days a week would you commit to exercise? 1 2 3 4 5 6 7

Realistically, how much time would you commit to spend during each exercise session? 30 Minutes 45 Minutes 1 Hour 1.5 Hours 2 Hours

Running/Walking
Biking
Swimming
Outdoor Activities
Recreational Activities
Golf

Aerobics
Dance
Yoga/Pilates
Martial Arts
Calisthenics
Conditioning

Circuit Training
Free Weights
Resistance Training
Athletics/Sports
Other

...in the past 6 months?

...in the past 5 years?

Are there any exercises or activities that you find painful or dislike? Yes No

If yes, please specify

Have you ever worked with a personal trainer? Yes No

Do you start exercise programs but then find yourself unable to stick with them? Yes No

Do you have the support of your family and/or friends to start a fitness program? Yes No

On a scale of 1 -10, how would you rate your nutrition (1 = Very Poor - 10 = Excellent)? 0 1 2 3 4 5 6 7 8 9 10

6 or more times a day
5-6 times a day

3-4 times a day
1-2 times a day

Whenever hungry
Strictly breakfast, lunch, & dinner

Almost every day
A few times a week

Once a week
A few times a month

Rarely or Never

Do you do your own grocery shopping? Yes No Do you do your own cooking? Yes No

Do you often skip meals? Yes No Do you regularly eat breakfast? Yes No

Do you eat late at night? Sometimes Often Rarely

Do you eat foods high in fat or sugar? Sometimes Often Rarely

Are there certain foods you crave? Yes No

If yes, please specify

Do you have any food allergies? Yes No

If yes, please specify

Are there any other foods you avoid or dislike?

Please list any vitamins or supplements you are currently taking