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Email
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Your email
Name
*
Your answer
Phone number
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Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Why do you want to join this program?
*
Your answer
On a scale of 1-10, with 10 being extremely happy, how would you rate your happiness in each of the categories below?
Exercise / Movement
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Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
Physical Health
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Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
Stress Level
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Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
Nutrition
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Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
Sleep
*
Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
Play
*
Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
Body Image
*
Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
Energy / Vitality
*
Not at all happy
1
2
3
4
5
6
7
8
9
10
Extremely happy
What kind of exercise do you currently do and how often?
*
Your answer
Do you have any current challenges or barriers to regular exercise?
Your answer
What type of equipment or gym do you have access to?
Your answer
What is your favorite way to exercise?
Your answer
Are there any types of exercise you don't like? If so, what?
Your answer
How many workouts do you want to do each week?
2
3
4
5
Clear selection
How much time are you willing to commit to exercise each day?
10 minutes or less
Between 10 and 30 minutes
Between 30 and 60 minutes
More than 60 minutes
Clear selection
Do you have any health concerns? Choose all that apply.
Insulin / Blood sugar
Blood pressure
Weight
Cholesterol
Smoking
Family History
Infertility
Back pain
Headaches
Menstrual cycle
Cancer
Diabetes
Other
Height
*
Your answer
Weight
*
Your answer
Do you have any injuries?
Your answer
Is there anything that might make exercise difficult or painful?
Your answer
What is your current stress level?
*
None
0
1
2
3
4
5
6
7
8
9
10
Very High
What is contributing to your stress?
Your answer
How do you manage your stress?
Your answer
What do you do for self care?
Your answer
Are you happy with your diet?
*
Yes
No
Are there any changes you'd like to make to your diet?
Your answer
Describe your typical breakfast.
Your answer
Describe your typical lunch.
Your answer
Describe your typical dinner.
Your answer
Describe your typical snacks.
Your answer
How often do you eat out?
Your answer
How often do you eat at home or make your own meals?
Your answer
What protein do you eat and how many servings per day?
Your answer
What vegetables and fruit do you eat and how many servings per day?
Your answer
How many alcoholic drinks do you have each week?
Your answer
Do you smoke?
Yes
No
Clear selection
What time do you go to bed?
Your answer
Do you wake at night?
Yes
No
Rarely
Often
Clear selection
What time do you wake up?
Your answer
Do you wake up feeling rested?
Yes
No
Clear selection
What do you do for fun?
Your answer
How do you unwind from work?
Your answer
What are the first words that come to mind when you see yourself naked?
Your answer
What are your best physical attributes?
Your answer
If you could, what would you change about your body or physical appearance?
Your answer
How often do you weigh yourself?
Your answer
How do you feel when you see the number on the scale?
Your answer
How is your energy in general?
*
Low
1
2
3
4
5
High
If you energy has a peak, when is it?
Morning
1
2
3
4
5
Evening
Clear selection
Is there anything else you'd like me to know?
Your answer
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