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Please fill out the following questionnaire. Your answers will be crucial in assisting you in reaching your goals.
If you are a human and are seeing this field, please leave it blank.
Zip / Post Code
Date of Birth
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
Do you frequently have pains in your chest when you perform physical activity?
Have you had chest pain when you were not doing physical activity?
Do you lose your balance due to dizziness or do you ever lose consciousness?
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
If you have marked YES to any of the above, please elaborate below:
Do you take any medications, either prescription or non-prescription, on a regular basis?
If Yes, what is the medication for?
How does this medication affect your ability to exercise or achieve your fitness goals?
Lifestyle Related Questions
Do you smoke?
Do you drink alcohol?
If "Yes", how many how many servings and what type of beverage?
How many hours do you regularly sleep at night?
On a Scale of 1-10 (10 being extremely active), how active is your job?
How much travel does your job require?
On a scale of 1-10, how would you rate your stress level? (10 being extremely stressed daily)
List your 3 biggest sources of stress
Who if anyone in your family is overweight?
No immediate family
Were you overweight as a child? If yes, what age?
When were you in the best shape of your life?
Have you been exercising consistently for the past 3 months?
When did you first start thinking about getting in shape?
What if anything stopped you in the past?
On a scale of 1-10, how would you rate your present fitness level? (10 being the fittest person you know)
Nutrition Related Questions
On a scale of 1-10, how would you rate your Nutrition? (10 being PERFECT nutritional profile)
How many times a day do you usually eat (including snacks)?
Do you skip meals?
Do you eat late at night?
How many glasses of water do you consume daily?
Do you feel drops in your energy levels throughout the day? If so, when?
Do you know how many calories you eat per day?
If "Yes", how many?
Are you currently taking a multivitamin or any other food supplements?
If "Yes", please list the supplements.
At work or school, do you usually...
How many times per week do you eat out?
Do you do your own grocery shopping?
Do you do your own cooking?
List 3 areas of your nutrition you would like to improve:
1. 2. 3.
Current Physical Activity
How often do you take part in physical exercise?
5-7 times per week
3-4 times per week
1-2 times per week
0 times per week
If your participation is lower than you would like it to be, what are the reasons?
Lack of Interest
Lack of Time
How long have you been consistently following your current physical activity regiment?
What physical activities are you presently involved in? (Include Activity, Frequency, Difficulty, and amount of time spent on each activity.)
If you could design your own exercise program, what would an ideal training week look like to you? Please be specific. List your favorite activities, rest days, time spent etc.
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
How can a Fitness Coach help you? Please check all that apply.
Lose Body Fat
Develop Muscle Tone
Rehab an injury
Get Start on an Exercise Program
Design a more advanced program
Sports Specific Coaching
Increase Muscle Size
Please list in order of priority, the 3 fitness goals you would like to achieve in the next 3-12 months?
1. 2. 3.
Where do you rate health in your life?
How committed are you to achieving your fitness goals?
What do you think the most important thing your Fitness Coach can do to help you achieve your fitness goals?
Describe aspects of your life that you foresee as potential challenges to achieving success (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise etc.).
How did you hear about us? (Please be specific with names)
How far do you live from our training facility? (in miles)