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Nutrition & Wellness Request Form - Nutrition

  1. Nutrition and Wellness Request Form

    Please complete this form if you are interested in receiving a nutrition consultation.

  2. Nutrition Logo

  3. Participant Information

  4. List times/days

  5. Additional Participant Information (if applicable)

  6. Current Physical Activity Level

  7. How many days per week do you exercise?*

  8. How many minutes do you spend exercising per workout?*

  9. Where do you exercise?*

  10. Why do you exercise?*

  11. Are you involved in a structured fitness program?*

  12. Have you had an InBody 570 body composition scan?

  13. PAR-Q (Physical Activity Readiness Questionnaire)

    For most people physical activity should not pose any problem or hazard. The Physical Activity Readiness Questionnaire has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly.

  14. PARTNER #1

  15. PARTNER #2

  16. Question 1*

    Has your doctor ever said you have a heart condition AND that you should only do physical activity recommended by a doctor?

  17. Question 1

    Has your doctor ever said you have a heart condition AND that you should only do physical activity recommended by a doctor?

  18. Question 2*

    Do you feel pain in your chest when you do physical activity?

  19. Question 2

    Do you feel pain in your chest when you do physical activity?

  20. Question 3*

    In the past month, have you had chest pain when you were not doing physical activity?

  21. Question 3

    In the past month, have you had chest pain when you were not doing physical activity?

  22. Question 4*

    Do you lose your balance because of dizziness or do you ever lose consciousness?

  23. Question 4

    Do you lose your balance because of dizziness or do you ever lose consciousness?

  24. Question 5*

    Do you have a bone or joint problem that could be made worse by a change in your physical activity?

  25. Question 5

    Do you have a bone or joint problem that could be made worse by a change in your physical activity?

  26. Question 6*

    Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure or heart condition?

  27. Question 6

    Is your doctor currently prescribing drugs (for example: water pills) for your blood pressure or heart condition?

  28. Question 7*

    Do you know of ANY OTHER REASON why you should not do physical activity?

  29. Question 7

    Do you know of ANY OTHER REASON why you should not do physical activity?

  30. If you answered YES to questions 1, 2, 3, 4 or 7...

    Talk with your doctor and have them fill out a Report of Physical Examination form (available at Guest Service) BEFORE you participate in a personal fitness training or fitness assessment. Tell your doctor about the PAR-Q and which questions you answered yes to.

  31. If you answered NO to all of the questions you can reasonably be sure that you can...

    Start becoming more physically active, beginning slowly and building up gradually. This is the safest and easiest way to go. Take part in personal fitness trainer or fitness assessment appointment; this is an excellent way to determine your basic fitness so you can plan the best way for you to live actively. You should delay becoming more physically active if you are not feeling well because of temporary illness such as a cold or fever OR if you are or may be pregnant. Please consult your physician before coming physically active.

  32. Health and Lifestyle Assessment Questionnaire

  33. Have you ever had an injury, surgery, or problem with any of the following areas?*

  34. Stress

  35. Energy and Sleep

  36. Do you experience any highs or lows throughout the day?*

  37. Do you wake feeling rested?*

  38. Do you ever wake at night and cannot go back to sleep?*

  39. Family History

  40. Have you or anyone in your immediate family had any of the following?*

  41. Be sure to indicate both the condition and the person.

  42. Have you ever consulted a medical doctor regarding the aforementioned conditions?*

  43. Was your mother in excellent health throughout her pregnancy while carrying you?*

  44. Were you breastfed at all?*

  45. Were you fed anything other than breastmilk during your first 6 months of life?*

  46. Were you a colicky baby?*

  47. Have you ever been diagnosed with an illness?*

  48. Have you ever been hospitalized?*

  49. Have you had any reoccurring infections or inflammations?*

    Examples include: Tonsilitis, Bladder or Ear Infection, Vaginitis, Colitis, Sinusitis, Yeast Overgrowth, Mastitis, Dental Abscesses, etc

  50. Have you had any respiratory disorders?*

    Examples include: Asthma, Bronchitis, Pneumonia, etc.

  51. Are they severe?

  52. Do you take any medications for the above?

  53. Do you have any allergies/intolerance to food, drugs, or inhalants?*

  54. Leave This Blank:

  55. This field is not part of the form submission.