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Potential Nutrition and Exercise client
In order to help you as best as I can I need to know who you are! Please complete the following questionnaire as honestly and as detailed as you can. Once complete you'll hear from me within 48 hours!
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* Indicates required question
Email
*
Your email
What is your name?
Your answer
What Is todays date?
MM
/
DD
/
YYYY
What is your birthdate?
MM
/
DD
/
YYYY
What is your phone number?
Your answer
Do you prefer I contact you via cellphone or email?
Email
Phone
Clear selection
What is your biological sex?
Male
Female
Clear selection
How much do you currently weigh?
Your answer
How tall are you?
Your answer
What do you do for work? Please describe a typical day.
*
Your answer
What are your current goals? Select all that apply
Lose weight/fat
Gain Weight
Maintain weight
Add Muscle
Improve overall health
Improve physical fitness
Look better
Feel better
Have more energy and vitality
Healthy aging
get control of eating habits
Get stronger
Physique competition/modeling (bodybuilding)
Improve athletic performance
Get off or decrease medications
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Your answer
Building off the previous question what are the most important changes you want to make in order of most important to least important?
Your answer
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body? If so what?
Your answer
If you were to consider making more changes to your habits, your health, your eating and or your body, what might those be?
Your answer
Until now, what has blocked you or held you back from changing these things?
Your answer
On a scale of 1-10 How would you rank your overall eating/nutrition habits at the moment?
Horrible
1
2
3
4
5
6
7
8
9
10
Excellent
Clear selection
Why’d you give yourself the score you did on the previous question?
Your answer
Are you regularly active in sports and or exercise?
Less than 5 hours per week
5-9 hours per week
10-14 hours per wek
15-19 hours per week
20 or more hours per week
Clear selection
What type of sports and or exercise do you do?
Your answer
If you were to start a workout program what days of the week would you like to workout?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Required
What is your ideal time limit for each workout? For example "I only want to workout for 45-60 minutes three days a week."
*
Your answer
What gym equipment do you have at home? Please list everything you have or let me know what gym you plan on working out at.
*
Your answer
Tell me about your environment. Who lives with you?
Spouse/significant other
Roommates
Child(ren)
Pet(s)
Other family, grandparents, siblings etc..
Do you have children? If so what are the name(s) and age(s)
Your answer
Who does most of the grocery shopping in your household?
Me
Spouse/significant
My parents
Roommate(s)
Child(ren)
Other family
Clear selection
Who does most of the cooking in the household?
Me
Spouse/significant other
Roommate(s)
Child(ren)
Other family
Clear selection
Who decides on most o the menus/meal types in your household?
Me
Spouse/significant other
Roommate(s)
Parent(s)
Child(ren)
Other family
Clear selection
Right now how much do the people and things around you support your health, fitness, and / or behavior change?
They don’t support me at all
1
2
3
4
5
6
7
8
9
10
I have the best support
Clear selection
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries
Yes
No
Clear selection
If yes, please explain and list all.
Your answer
Right now are you taking any medications, either over-the-counter or prescription?
Yes
No
Clear selection
If yes please list your medications (this is kept completely confidential and used only to check for contraindications with exercise and or fat loss)
*
Your answer
On a scale of 1-10 how would you rate your health right now?
Very Poorly
1
2
3
4
5
6
7
8
9
10
Very Healthy
Clear selection
On a scale of 1-10 ow do you feel about your schedule, time use, and overall busy-ness?
My life is panicked and insane
1
2
3
4
5
6
7
8
9
10
My life is perfectly calm and relaxed
Clear selection
How is your stress level and recovery? Think about all the activities you’re involved in such as work, school, caregiving, housework, travel. Then assess as best you can, what you stress level is on a typical day.
No stress at all
1
2
3
4
5
6
7
8
9
10
Extremely stressed almost always
Clear selection
On average how many hours per night do you sleep?
4 or less most nights
5 hours most nights
6 hours
7 hours
8 hours
9 hours
10 or more hours
Clear selection
How do you normally cope with stress? Any or all of the following could be appropriate answers; I stuff my face with delicious foods that probably aren’t good for me. I acknowledge how I feel and choose to control my emotions. I get angry and lash out someone. I get physical so I normally go to the gym or outside. How do you deal with stress?
Your answer
How would you rate your energy level on average?
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No energy ever
1
2
3
4
5
6
7
8
9
10
All the energy, I'm Tiggr (winnie the pooh)
Are you local in Owensboro, KY? If so do you want in-person personal training?
*
Yes
No
Do you want Nutrition and Exercise Coaching to maximize your results?
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Yes
I want Nutrition Coaching Only
I want exercise coaching only
Whatever you recommend
Other:
How READY are you to change your behaviors and habits?
I’m not ready
1
2
3
4
5
6
7
8
9
10
Let’ s do this!
Clear selection
How WILLING are you to change your behaviors and habits?
I’m not ready
1
2
3
4
5
6
7
8
9
10
Let’s do this!
Clear selection
How ABLE are you to change your habits?
I’m not ready
1
2
3
4
5
6
7
8
9
10
Let’s do this!
Clear selection
What do you expect from me as your coach?
Your answer
What are you prepared to do to work towards your goals?
Your answer
Lastly, Why now? Why start taking your health seriously right now?
*
Your answer
Disclaimer: Please recognize that it is your responsibility to work directly with your healthcare provider, before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to crept full responsibility for your decision.
Yes, I understand and hereby give my approval to let DG FIT provide nutrition and or fitness consultation to me
I do not agree to let DG FIT provide nutrition and or fitness consultation to me.
Clear selection
Thank you for completing this short application! I will reach out to you via your preferred contact method as soon as I can. Most likely we will meet in person or schedule a call next. I look forward to working with you!
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