PAFE Initial Questionnaire
Fill this questionnaire out at least 24 hours of your consultation with PAFE to receive the most personalized experience we can give you.  If it isn't completed, we may end up covering much of these questions in your consultation instead.  Please note that your answers and personal information will be shared with no one except your health coach.
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Email *
First and Last Name *
Gender *
Email address *
Phone number including area code *
May we health coach text you on this number?  This wouldn't be for any SPAM or mass-texting messages. *
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Street address, including state, country and zip code *
Birthdate (MM/DD/YYYY) *
Do you have regular access to a computer or tablet? *
If you do not have regular access to a computer or tablet, are you okay with receiving health coaching and/or personal training video sessions on just a smart phone? *
Emergency contact name and 10-digit phone number  (Why do we need this?  If you are doing a personal training session and become ill or injured, we need to notify someone.) *
EMS Response contact information (Example: you're in a personal training session, slip, fall, hit your head and you're home alone... we will get you some help!) *
What are the goals you hope to achieve by working with a health coach from PAFE? *
What nutrition, diet and fitness changes have you tried in the past?  Please include as much as you can remember on this topic? *
Of your previous attempts at better fitness and nutrition goals, what aspects worked, or were things you enjoyed? *
Of your previous attempts at better fitness and nutrition goals, what aspects definitely didn't work, and were things you didn't enjoy? *
Please list any health conditions you may have, either diagnosed or not, and whether or not you think that they may affect your goals in this program.  Again, this information and any of the information generated from the following questions will stay confidential with your coach only, and is used only so that program design can be done in a way that is most healthy and beneficial for you. *
Please list any surgeries you have had in the past. *
Please list any musculoskeletol injuries you have had in the past. *
With any surgeries or injuries, where they properly rehabilitated and you have received medical clearance from a doctor to return to physical activity? *
Are you currently taking any medication? *
If yes, please explain *
Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary disorders, high cholesterol, hypertension, diabetes, or cancer)? *
If yes, please explain. *
Do you deal with any chronic pain? *
If yes, please explain *
Which part of the PAFE program do you want to focus on the most? *
Required
Have you ever worked with a health coach before in any capacity? *
If yes, please describe what type of services you received and any likes or dislikes about it. *
What your family life at home?  Please include if you have children, age ranges, significant others, or if you are a caretaker for anyone else at home.  Pets should be included here too! *
What kind of work life do you have?  What do you do?  How active is it?  Full or part-time?  Please mention if you are retired, a student or are at a stay-at-home or work-from-home status. *
Does your work life require you sit for extended periods of time? *
Does your work life require you do wear a certain type of shoe? (Examples are work boots, high heels, etc.) *
If yes, please explain. *
Does your occupation require repetitive movements? *
If yes, please explain. *
Does your work life cause you mental or emotional stress? *
When stressed out, what do you generally do to cope with it? *
What type of hobbies do you enjoy?  Please include active and non-active hobbies. *
Height *
Weight *
Do you have any dietary preference?  Please include any allergies, vegetarian, vegan, gluten free, foods you absolutely hate, doctor-prescribed diets, etc. *
How are your sleep habits?  Restful?  How many hours usually? *
On a scale of 1 to 10, how healthy is your average diet? *
Junk food all the time
Very health and balance with no, or almost no junk food.
On average, how many 8 oz. cups of water do you drink each day?   *
Do you smoke or vape? *
How many caffeinated beverages would you say you have each day? *
How would you rank your daily sodium intake? *
How would you rank your daily sugar intake? *
On a scale of 1 to 10, how effectively are you able to resist cravings and temptations for unhealthy foods? *
Never can
Always can
About how many alcoholic beverages do you consume each week? *
How stressed out are you lately? *
No stress at all
I'm so stressed that it affects my daily life.
Do you have or use any fitness wearables?  Ex. Fitbit, phone apps that track steps, etc.  What do you have or use? *
What kind of exercise or physical activity do you currently engage in?  If nothing right now, please type "None." *
Do you have financial resources available to invest in your goals right now? *
Please describe the space you may have set aside for any type of home fitness training. *
Please list any fitness equipment you have at home. *
Is there any additional information that you would like to share with your health coach that you believe would help them help you even better?  Please type "none" if you cannot think of anything else. *
Lastly, if you haven't booked your free strategy call, click here to do so: https://pafenutritionandfitnesswithkdjski.setmore.com/  *
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