Lifestyle Questionnaire

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Name *

Date of birth

YYYY

What are you looking to achieve with your new lifestyle? (Choose more than one if appropriate) *

To improve your sports performance and recovery

To increase overall level of wellbeing

To improve healthy habits/behaviours

To decrease body measurements

To improve your diet

To decrease weight

To gain weight

Other:

Required

What are the current reasons you have to achieve the above goals? *

If looking for weight or body composition change please provide your current weight

Height

What is your day to day occupation *

What is your average day to day WORKING activity level? (Please choose) *

Light – eg. desk bound, mainly seated or immobile, very little activity

Moderate – e.g. some floor walking, moderately active, some lifting

Heavy – e.g. regular strenuous activity, continuous movement

What activities do you do in your spare time - how often and duration *

When would you like to achieve your goals by? *

YYYY

How motivated are you currently to achieve these goals? (1=not at all) *

Have you attempted to achieve the above goals in the past? (Please choose one) *

Yes – I did not achieve them

Yes – I did achieve them

No – It is my first time

Can you list any obstacles you may face in achieving these goals now? *

Can you list any support and/or reasons that may help you in achieving your goals? *

What fitness facilities or equipment, if any, do you have available to use throughout your programme? *

Client Electronic signature *

SIGNED

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