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Welcome To TTFit.com... Tight - Toned - Fit :: We're your # 1 source for Professional Body Sculpting and Fitness Consulting!.... "REMEMBER RESULTS ARE NOT GUARANTEED; THEY'RE ACHIEVED THROUGH HARD WORK THAT'S DRIVEN BY DETERMINATION AND COMMITMENT....."
Terry's Total Fitness, TTFit.com
Fitness, Nutrition & Supplement Guidance Questionnaire

*Please note we only accept questionnaires from those who reside in the United States and are 18 years of age or older. We apologize for any inconvenience. Also Note: If you fill out our questionnaire and wish not to have us contact you by phone, we can not help you.

Please take your time when filling out our fitness questionnaire. Your answers to the questions are important, so we can evaluate them and make safe and effective recommendations for your exercise, nutrition or supplement program.

** means a required field.

Date:
First Name: **
Last Name: **
Age: **
Gender: **
Address: **
City: **
State: **
Zip: **
Daytime or work phone: **
Evening or home phone: **
Best time to contact: **
Fax:
Email address: **
 
Do you want to be contacted by phone to review your questionnaire and discuss a customized nutritional supplement program? Yes   No 
Please give a brief description of the health and fitness goals you are trying to improve or achieve. **
ENERGY
How are your energy levels throughout the day?
Do you need more energy or stamina during your workouts? Yes   No
Do you get sleepy or lethargic after eating? Yes   No
NUTRITION
How many meals do you eat per day?
Do you skip meals? Yes   No
If so, which meals do you skip on most days?
What time do you eat breakfast? (please indicate am or pm)
What time do you eat lunch? (please indicate am or pm)
What time do you eat dinner? (please indicate am or pm)
Do you eat snacks? Yes   No
If so, when do you snack? Check all that apply. Between breakfast & lunch Between lunch & dinner Between dinner & bedtime Middle of the night
How many times per week do you eat fatty foods, fast foods or fried foods?
Do you crave sweets or carbohydrates? Yes   No
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.)
How many cups of coffee, tea, soda, or other caffeinated beverages do you consume each day?
Are you over sensitive to caffeine? Yes   No
Are you allergic to seafood? Yes   No
Are you allergic to any soy products? Yes   No
Are you currently dieting? Yes   No
Are you currently or have you ever taken any product to enhance weight loss? Yes   No
Do you have problems swallowing or taking pills or vitamins? Yes   No
SUPPLEMENTATION
Do you currently take any over-the-counter nutritional supplements? Yes   No
If so, indicated which ones you are currently taking:
Are you currently taking a protein supplement (shakes or bars) to round out your diet? Yes   No
Are you currently taking any type of creatine supplement? Yes   No
List any other nutritional supplements that you are currently taking:
DIGESTION
How is your digestion? Indicate the number of daily bowel movements you have:
Do you suffer from indigestion or have any gastro-intestinal problems? Yes   No
FITNESS
Are you currently exercising? Yes   No
What time of day do you usually train? (please indicate am or pm)
How many times a week are you doing some type of cardiovascular fitness (walking, jogging, running exercising?
Check the types of cardiovascular fitness you currently participate in: Walking Jogging Running Treadmill Elliptical training Stationary bike Recumbent bike Bicycle Aerobics class Other
Are you currently weight training as a part of your exercise program? Yes   No
What time do you exercise each day?
Where do you currently exercise?
If home or gym, explain what type of equipment you are using?
Do you currently suffer from any joint pain from a previous injury (tendon, cartilage, etc.) that prevents you from being as active as you would like? Yes   No
Do you have problems with muscle cramping during exercise or workouts? Yes   No
Do you wish to have faster recuperation following exercise? Yes   No
Is there any reason at all (health or personal) that would limit or prevent you from exercising? Yes   No
REST
How many hours of sleep do you get on an average night?
What time do you generally go to bed? (please specify am or pm)
What time do you generally wake up? (please specify am or pm)
Do you suffer from insomnia or have trouble sleeping? Yes   No
GENERAL HEALTH
Height:
Current weight: (specify lbs or kg)
Weight 1 year ago: (specify lbs or kg)
How much weight would you like to lose?
How much weight would you like to gain?
Do you consider yourself to have a high stress level? Yes   No
Is your total cholesterol greater than 200?
Do you have weak bones? Yes   No
Do you desire increased anti-oxidant and/or anti-aging protection? Yes   No
Do you smoke? Yes   No
If yes, how many packs per day?
Do you drink alcohol? Yes   No
If yes, how many drinks per week?
WOMEN'S HEALTH QUESTIONS (skip if male)
Are you post-menopausal? Yes   No
Do you suffer from hot flashes? Yes   No
Are you pregnant or lactating? Yes   No
MEDICAL INFORMATION
Do you have any of the following conditions? Check all that apply: Diabetes Hyperthyroidism High blood pressure Heart problems Coronary artery disease
Do you suffer from a degenerative disease (osteoarthritis, osteoporosis, etc.)? Yes   No
Do you suffer from fibromylaygia or overall aches and pains? Yes   No
Do you or your children suffer from attention deficit disorder? Yes   No
Do you suffer from anxiety? Yes   No
Do you ever feel faint or dizzy? Yes   No
Are you currently taking any prescribed medication? Yes   No
Have you had surgery in the last year? Yes   No

Thank you for taking the time to fill out this questionnaire. If you checked the box above allowing us to contact you, we will call or e-mail you within 24-48 hours to discuss your questionnaire and a customized nutritional supplementation program built for you.

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

Product and Services Disclaimer For TTFit.com:

Any Purchaser of the services or products provided by Terry Gednalske owner of Tight - Toned - Fit (TTFit.com) assumes all risks, Known and Unknown, inherent to exercise and workout programs, diet programs, supplements and physical changes or injuries which may result from the use of such products and services. Purchaser agrees to hold Terry Gednalske and TTFit free from any and all liability resulting from the services or products offered. Purchaser agrees that the laws of the State of Texas apply to this agreement.

As with any exercise or diet program, purchaser with a personal history or family history of health problems should consult with a physician before embarking on a new exercise or diet program. I am over the age of 18 yrs. old and have read and fully understand the contents of this contract and agree to its terms an conditions in full.

** By placing your initials in the provided box, you are digitially signing that you understand and agree to the disclaimer terms, and conditions. You must initial the box.

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