TMP Questionnaire | TweakMyProgram

Name *

First

Last

Email *

Phone # *

Sex *

Male
Female

Age *

Please check the category that best describes your fitness goals: *

How much do you weigh now? *

What is your goal weight?

What is your approximate height? *

Do you know your approximate bodyfat percentage (%) ?

Yes
No

If Yes, what is it and how was it measured?

What is your goal bodyfat percentage (%) ?

How many days a week are you currently exercising? *

Include both cardiovascular and resistance exercise.

Please describe your current weekly exercise routine:

Are you currently following any of these mainstream diets?

Describe your current nutrition plan including any dietary habits that you feel currently prevent you from reaching your fitness goals (sweets, late night eating, alcohol, fast foods, etc.):

Please list any nutritional supplements you are currently using:

Do you have any health problems or physical disabilities? *

Yes
No

If Yes, please describe or list:

Are you currently taking any prescription medication? *

Yes
No

If yes, please list:

Do you currently smoke cigarettes? *

Yes
No

If Yes, how much?

Please include any other information you feel is pertinent to your program participation:

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