Client Data Profile Step 1 of 5 - Form Type 20% Form Type*Weight Loss or Nutrition ConsultationSports Consultation First Name*Middle InitialLast Name*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Gender*MaleFemaleDate of Birth* MM DD YYYY Age*What is your current occupation?*Mark the one that best applies best*Full-TimePart-TimeNot Working/RetiredNormal Working Hours*(Ex. 7am-4pm)Does your job require shift work?*YesNoMarital Status*MarriedSingleDivorced/SeparatedDo you have any children?*YesNoNumber of Children*Children's Ages*How were you referred?*Current weight?*Current height?*Goal weight?* Please check if you have or been treated for any of the following:* Diabetes (type 1) Diabetes (type 2) Depression Thyroid Disease Anorexia/bulimia Heart Disease Heart attack/Bypass High blood pressure Gallbladder disease Glaucoma Cholesterol Hypoglycemia Cancer Immune System Disease Gastrointestinal disorder Anemia Arthritis Gout Insulin Resistance or PCOS Osteoporosis Anxiety Triglycerides Other None Please Specify Other*Do you have food allergies?*YesNoPlease list food allergies:* Have you had any surgeries?*YesNoPlease explain and give dates*Are you pregnant?*YesNoAre you breastfeeding?*YesNoDo you experience any of the following:* Headaches Constipation Diarrhea Indigestion Kidney Trouble Leg Cramps Loss of Hair Excessive fluid retention No Appetite Dry skin Tiredness Bladder Trouble Difficulty Sleeping Asthma Fainting Spells Swollen hands/feet None If you know the following, please complete:Cholesterol:Include dateHDL:Include dateLDL:Include dateTriglycerides:Include dateGlucose:Include dateHgbA1C:Include dateDo you take medication?*YesNoPlease list all medications:* Are you currently under a physician's care for any acute or chronic condition?*YesNoPlease ExplainIf previously mentioned, please skip.Are you currently on a diet prescribed by your doctor?*YesNoPlease explain:*Family History* Cancer Heart Diabetes Depression High Blood Pressure Anxiety None Do you take vitamin supplements such as vitamin C, calcium, or other nutrient supplements on a typical day?*YesNoIdentify what you are taking:* Antioxidants Calcium Folate or folic acid Vitamin E Fish Oil Vitamin C Multi-Vit Other Please list other supplements:* Are you currently exercising?*YesNoList type, duration, frequency and intensity of exercise activites:*What nutritional supplements or foods, if any, do you use during a workout session?*Please describe when the supplement is used, for example: before, during or after workoutAre you currently under any type of exercise limitations or restrictions?*YesNoPlease explain*Describe your current exercise routine:*Do you lack energy?*YesNoStress level*HighModerateLowPlease explain:*In the last five years, what was your highest weight?*What was your lowest weight?*What methods have you used to lose weight in the last three years?* What beverages do you drink?* Coffee Tea Diet Soft Drinks Alcohol Water Milk Juice Sports Drinks Sugar-Free Drinks other than Soda Please list type and how many per day or how often?* On most days, how many meals/snacks do you eat?*Please answer with a whole number.How many meals per week do you usually eat out?*Count meals prepared by a commercial food service, restaurant, deli or fast food provider. Please answer with a whole number.How often do you eat breakfast?*EverydaySome daysMost daysRarely or neverDo you skip lunch?*YesNoWhich family member/s do the grocery shopping?*Which family member/s do the majority of the cooking?*Please list your dietary recall for the last 24-hours including fluid intake:* Breakfast Snack Lunch Snack Dinner Snack Other None Specify what meal time and what was consumed:* Waist measurement:* This iframe contains the logic required to handle Ajax powered Gravity Forms.