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Lifestyle Questionnaire
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* Indicates required question
Name
*
Your answer
Date of birth
MM
/
DD
/
YYYY
Weight
Your answer
Height
Your answer
What is your day to day occupation
*
Your answer
What is your average day to day working activity level? (Please choose)
*
Light – eg. mainly seated or immobile, very little activity
Moderate – e.g. moderately active, some walking, some lifting
Heavy – e.g. regular strenuous activity, continuous movement
What activities do you do in your spare time - how often and duration
*
Your answer
What are you looking to achieve with your new lifestyle? (Choose more than one if appropriate)
*
To decrease weight
To gain weight
To decrease body measurements
To increase overall level of wellbeing
To improve your diet
To improve your sports performance and recovery
Other:
Required
What are the current reasons you have to achieve the above goals?
*
Your answer
When would you like to achieve these goals by?
*
MM
/
DD
/
YYYY
How motivated are you currently to achieve these goals? (1=not at all)
*
1
2
3
4
5
6
7
8
9
10
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?
*
Your answer
Can you list any support and/or reasons that may help you in achieving your goals?
*
Your answer
What fitness facilities or equipment, if any, do you have available to use throughout your programme?
*
Your answer
Client Electronic signature
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