Diet Questionnaire

Connecticut's Longest Running Personal Training Center - Established 1988

Over the years I have found that "off the shelf" diets rarely work. People have their own likes, dislikes, lifestyles and goals. So how can one diet work for all? Simply stated, it cannot. Generic diets have little value, but for the dieter, they come with high expectations....expectations that are rarely met.

When planning a diet exclusively for you, there are questions to be asked and answered. A winning diet plan considers your individual needs. A diet built expressly for you will work with some focus and willpower from you. With a fuller understanding of cravings, good food, when and what to eat and how exercise factors into your plan, you can achieve and maintain the results you are looking for.

Along with motivation and commitment to success there will be changes. Once you have made up your mind to live a healthier life, you will welcome these changes. If you already eat sensibly and are not getting the results you desire, subtle changes may be all that are necessary. Changes can be as simple as rearranging what you eat at a particular meal, the number of meals eaten in a day and the amount you eat at those meals. These changes can create dramatic results.

If your diet needs are more challenging, there is no reason to expect that you will not meet your goals. Experience has shown me that by educating motivated people about food and planning a healthy diet designed to meet individual goals, success is a given. Finding the right foods and building them into a healthy diet plan is part of what this questionnaire is all about.

These questions are designed to assist me in developing a clear and complete understanding of you and your goals. Some questions may strike you as personal in nature. They are, but please recognize that the value of your answers provide me with a fuller understanding of you and your goals. If you chose to skip a question, the only consequence is that I will have less information with which to work.

Please be honest in your answers. If you skip breakfast, eat potato chips and coke for lunch and grab a triple burger at the local fast food stand for dinner, say so. My purpose is not to judge you but rather to understand you and help you attain your goals.

The price for this service is $120.00. Please complete the form below. When you have finished the questionnaire, press the "Submit Questionnaire" button at the bottom of this screen. When you have submitted your questionnaire, please make a check out to Butch Paradis in the amount of $120.00 and mail it to:

Butch Paradis
200 Blakeslee Street
Unit #200
Bristol, CT 06010

Normally it takes about two weeks to receive your new diet.

Questionnaire

GOALS

Please let me know what the goal of this diet will be by checking all that is applicable
Weight reduction
Weight gain
Increased muscle mass
Other (please specify reasons in box below)

DIETING HISTORY

Is this your first time dieting? Yes No

If not, what other programs have you used?

If over 30 what was your weight at 21? lbs.

What has your lightest weight been? lbs.

What has your heaviest weight been? lbs.

What is your most troublesome area?

EXERCISE

Do you exercise? Yes     No

If so, what days of the week do you exercise? Sun Mon   Tue   Wed
Thur   Fri     Sat

How many months or years have you exercised? Months    Years

If you do not exercise now, when was the last time you did?

SLEEP SCHEDULE

What time do you go to bed? AM PM

What time do you wake? AM PM

MEALS

At what time do you generally eat your meals? Where are most meals eaten?
(home, work, restaurants, etc.)

Meal 1 AM PM

Meal 2 AM PM

Meal 3 AM PM

Meal 4 AM PM

Meal 5 AM PM

Meal 6 AM PM

Is there a cafeteria available at work? Yes     No

At work, do you have access to a microwave, blender, and refrigerator? Yes     No

Are you willing to take supplements? Yes     No

What are the foods you really dislike?

Please describe your daily diet.

MEDICAL PROBLEMS (please check all that apply)

Diabetic High Cholesterol

Heart Food Allergies

High Blood Pressure Other

PERSONAL INFORMATION

Age Years

Height Ft   Inches

Weight Lbs

Sex Male          Female

Marital Status Married     Single

Type of work Mental    Physical

Work Hours From AM      PM
To       AM      PM

Do you smoke? Yes     No    If yes, how much?


Do you drink alcohol? Yes     No     If yes, how much?


Number of children

HOW CAN I REACH YOU:

Name
Address Line 1
Address Line 2
City, State Zip
E-mail Address
Telephone