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Nutritional Supplement
Guidance Questionnaire



 

Please fill out this form in its entirety. This gives Merlino Fitness important information about your goals, fitness level, nutrition habits, medical history, and more. All information is kept confidential and helps Michael design a supplement plan that is right for you. Please allow about 10 minutes of your time to complete and we will contact you as soon as possible. Thanks and we look forward to receiving your questionnaire!

Date

First Name

Last Name

Age

Sex

Address


City

State

Zip

Work phone

Home phone

Pager

Cell phone

Best time to contact

Fax

Email address


Why are you filling out this questionnaire? Please check all reasons that apply.
I am a new Merlino Fitness client.
I just purchased fitness services from the Merlino Fitness online store.
I am interested in personal training or fitness consulting with Merlino Fitness.
I am interested in nutritional guidance or a customized nutritional supplement program from Merlino Fitness.

Please give a brief description of the health and fitness goals you are trying to achieve or improve .

ENERGY

  1. How are your energy levels throughout the day?
  2. Do you need more energy or stamina during your workouts?
    Yes   No
  3. Do you get sleepy or lethargic after eating?
    Yes   No

NUTRITION

  1. How many meals do you eat per day?
  2. Do you skip meals? Yes   No
  3. If you skip meals, check which ones you skip on most days? Breakfast Lunch Dinner
  4. What time do you eat breakfast?
  5. What time do you eat lunch?
  6. What time do you eat dinner?
  7. Do you eat snacks? Yes   No
  8. If you eat snacks, check all snack times that apply?
    Between breakfast & lunch Between lunch & dinner
    Between dinner & bedtime Middle of the night
  9. What do you normally eat prior to a workout?
  10. What do you normally eat following a workout?
  11. How many times per week do you eat fatty foods, fast foods, or fried foods?
  12. Do you crave sweets or carbohydrates?
    Yes   No
  13. How many servings of fruits and vegetables do you eat daily? A serving equals 1/2 cup of cooked or raw vegetables; 1 cup of leafy vegetables; 1/2 cup of fresh, frozen or cooked fruit or 1/4 cup of dried fruit.
  14. How many cups of coffee, tea, soda, or other caffeinated beverages do you consume each day?
  15. Are you over sensitive to caffeine?
    Yes   No
  16. Are you lactose intolerant or allergic to any dairy products?
    Yes   No
  17. Are you allergic to seafood?
    Yes   No
  18. Are you allergic to soy products?
    Yes   No
  19. List all other food allergies.
  20. Are you currently dieting?
    Yes   No
  21. Are you currently or have you ever taken any product to enhance weight loss?
    Yes   No
  22. Do you have problems swallowing or taking pills or vitamins?
    Yes   No
  23. Would you be interested in purchasing personalized, nutrition sessions or phone coaching from Registered Dietitian, Amy Carlson, to help you reach your nutritional goals?
    Yes   No

SUPPLEMENTATION

  1. Do you currently take any over the counter vitamins or nutritional supplements? Yes   No
  2. Check those vitamins that you are currently taking: Multi-vitamin Vitamin C Antioxidants Essential Fatty Acids Calcium Iron Other
  3. List any other vitamins or nutritional supplements that you are now taking below?
  4. Are you currently taking a protein supplement (shakes or bars) to round out your diet?
    Yes   No
  5. Are you currently taking any type of creatine supplement?
    Yes   No
  6. Do you desire increased anti-oxidant protection?
    Yes   No
  7. Would you be interested in a customized, daily vitamin supplement formulated specifically for your body type?
    Yes   No

DIGESTION

  1. How is your digestion? Indicate the number of daily bowel movements.
  2. Do you suffer from indigestion or have any gastro-intestinal problems?
    Yes   No

FITNESS

  1. Are you currently exercising?
    Yes   No
  2. How many times a week are you doing some type of cardiovascular fitness (walking, jogging, running, exercising)?
  3. Check below the types of cardiovascular fitness you currently participate in.
    Walking Jogging Running Treadmill
    Elliptical training Stationary bike Recumbent bike
    Bicycle Aerobics class Other
  4. Are you currently weight training as a part of your exercise program?
    Yes   No
  5. If you are weight training, indicate what type of equipment you are using.
    None Free Weights Machines Other
  6. What muscles fatigue quickly while weight training? Check all that apply.
    Abdominals Hamstrings Quadriceps (thighs) Calves
    Chest Neck Upper back Mid back
    Low back Shoulders Biceps Triceps
  7. What time do you exercise each day?
  8. Where do you currently exercise?
  9. Do you currently suffer from any joint pain from a previous injury (tendon, ligament, cartilage, etc.) that prevents you from being as active as you would like?
    Yes   No
  10. Do you have problems with muscle cramping during exercise or workouts?
    Yes   No
  11. Do you wish to have faster recuperation following exercise?
    Yes   No
  12. Is there any reason at all (health or personal) that would limit or prevent you from exercising?
    Yes   No
  13. If you have exercise limitations, please list the reasons you cannot exercise below.
  14. Would you be interested in purchasing personalized, fitness sessions or phone coaching from Certified Professional Fitness Trainer, Michael J. Merlino, to help you reach your fitness goals?
    Yes   No

REST

  1. How many hours of sleep do you get on an average night?
  2. What time do you generally go to bed?
  3. What time do you generally wake up?
  4. Do you suffer from insomnia or have trouble sleeping?
    Yes   No

GENERAL HEALTH


    Height:

    Current Weight:

    Weight 1 year ago:
  1. How much weight would you like to lose?
  2. How much weight would you like to gain?
  3. Do you consider yourself to have a high stress level?
    Yes   No
  4. Is your total cholesterol greater than 200?
  5. Do you suffer from weak bones and/or joints?
    Yes   No
  6. Do you smoke? Yes   No
  7. If you smoke, how many packs per day?
  8. Do you drink alcohol? Yes   No
  9. If you drink alcohol, how many drinks per week?

WOMEN'S HEALTH

  1. Are you post-menopausal? Yes   No
  2. Do you suffer from hot flashes? Yes   No
  3. Are you pregnant or lactating? Yes   No

MEDICAL INFORMATION

  1. Do you have any of the following conditions? Check all that apply
    Asthma Diabetes Hyper thyroid Hypo thyroid
    High blood pressure Heart problems Coronary artery disease
  2. Do you suffer from joint pain or any degenerative disease including osteoarthritis, osteoporosis, etc.?
    Yes   No
  3. Do you suffer from fibromylagia or overall aches and pains?
    Yes   No
  4. Do you or your children suffer from attention deficit disorder (ADD)?
    Yes   No
  5. Do you suffer from anxiety?
    Yes   No
  6. Do you ever feel faint or dizzy?
    Yes   No
  7. Are you currently taking any prescribed medications? Yes   No
  8. Have you had surgery in the past year? Yes   No

Thank you for filling out our questionnaire. We will call or e-mail you within 48 hours to review your questionnaire. Merlino Fitness is a no spam zone and we truly respect your internet privacy. We DO NOT share your information with any other individuals, companies or web sites. All information included in this questionnaire is held strictly confidential.

By clicking on submit below, I certify that I am over the age of 18 and have read and fully understand the contents of the Merlino Fitness disclaimer and agree to its terms and conditions in full.

If I have a medical condition, and/or if I am currently taking prescribed medications, it is recommended that the use of nutritional supplements should be coordinated with my physician or a registered dietitian. Some nutritional supplements may interact with medical conditions or prescribed medications.

Thank you for your time!

Click "Send!" to send us your form or reset to start over.

   

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Merlino Fitness • PMB 267, 1302 Waugh Drive • Houston TX 77019 • 713.523.2577

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