PT Lifestyle Assessment Form
Congratulations on taking a step towards a healthier you! I am here to help, but have few questions to ask prior to embarking on your fitness journey. Please read each question below and answer honestly. I will be in contact with you within 3-5 business days. Your information is kept private and confidential.
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Email *
Name: *
Preferred method of contact & contact information: *
What brings you to this particular program? *
On a scale of 0-10, how do you rate your fitness level? *
NOTHING - barely alive!
Exceptional-super fit!
What is your current exercise program? (types, duration, intensity and frequency) *
What kind of activities do you enjoy? *
On a scale of 0-10, how do you rate your eating habits? *
Poor
Perfect!
Explain your nutrition and supplementation regime. (i.e eating habits,caloric/protein/fat intake if possible, vitamins, weaknesses) *
On a scale of 0-10, how do you rate your stress level? *
Barely there!
TO THE MAX!!
How are you managing stress? (Meditation, Massage, breathing techniques, etc) *
How many hours of sleep are you currently getting each night? *
What areas of personal health would you like to improve? *
What is your biggest excuse for not taking action towards a healthier lifestyle? (Time, money, lack of knowledge, etc) *
Do you have any injuries or problematic areas? If yes, how are you managing? *
What is a short term goal that you would like to achieve? ( A short-term goal is something you want to do in the near future- within the next week, month(s) ) *
What is a long term goal that you would like to achieve? (Long-term goals usually take 12 months or more to achieve.) *
A copy of your responses will be emailed to the address you provided.
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