Basic Information

Name Date

Address City State

Zip Code Email Address

Daytime Phone No Evening Phone No. Sex Male Female

Age Height Weight Emergency Contact Phone

Relationship Date of Birth

What is your current weight?

What do you consider a good weight for you?

What is the most you have ever weighed?

Have you lost weight recently? Yes No If so, How much?

Have you gained weight recently? Yes No If so, How much?

Are you under a doctor's care? Yes No

If so, For what?

Exercise

Do you exercise? Yes No If not, Why?

Types How Often (times/week)

Duration