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Introductory Questionnaire
Please take a moment to fill out this form to help us get to know you.
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* Indicates required question
Name:
*
Your answer
Age:
Your answer
Height (cm):
Your answer
Occupation:
Your answer
What are your goals? (Select as many as relevant to you.)
*
Lose fat
Building muscle
Gain strength
Manage weight
Perform better
Feel my best
Reduce stress
Master my nutrition
Other:
Required
I am enquiring about: (Select as many as relevant to you.)
*
Group Classes
Kickstart Nutrition Coaching
Personal Training
Pre/Post Natal Consultation or Training
Dietitian Consultation
Body Composition Analysis
Not sure yet
Other:
Required
On a scale of 1-10 how motivated are you to achieve your goals?
*
I'd rather watch Netflix.
1
2
3
4
5
6
7
8
9
10
I'll do what ever it takes!!
Do you have, or have you had any health conditions?
*
Heart Condition
Type I Diabetes
Type II Diabetes
Eating Disorder
High Blood Pressure
Anxiety
Depression
Other
None
Required
If you have or had any of the above, please provide details or
describe any health conditions.
Your answer
Do you have, or have you had any pain or major injuries? (Only need to answer if you have)
Your answer
Do you have an ideal time frame to achieve your goals? (Only need to answer if you do)
Your answer
How many days per week are you currently exercising?
*
Not currently
0
1
2
3
4
5
6
7
Every day
What type of exercise are you doing or done in the recent past?
*
Strength Training
HIIT/Conditioning
Yoga/Pilates
Running
Walking
None
Other:
Required
Have you tried to change your body composition in the past?
Yes
No
Clear selection
If you answered yes, what have you tried?
Your answer
Do you currently take any supplements?
Yes
No
Clear selection
If you answered yes, please provide details.
Your answer
Do you currently take any prescribed medications?
Yes
No
Clear selection
If you answered yes, please provide details.
Your answer
Have you ever used a nutrition program?
Yes
No
Clear selection
If you answered yes, please provide details.
Your answer
On a scale of 1-10, how would you rate your overall stress levels throughout the course of the day?
Very Low
1
2
3
4
5
6
7
8
9
10
Very High
Clear selection
How many hours of sleep do you average per night?
< 5 Hours
6 - 7 Hours
7 - 8 Hours
> 9 Hours
Clear selection
On a scale of 1-10, how would you rate your overall energy levels throughout the course of the day?
Very Poor
1
2
3
4
5
6
7
8
9
10
Very Good
Clear selection
On a scale of 1-10, how would you rate you digestion?
Very Poor
1
2
3
4
5
6
7
8
9
10
Very Good
Clear selection
On a scale of 1-10, how would you rate your appetite?
Always Feel Hungry
1
2
3
4
5
6
7
8
9
10
Never Feel Hungry
Clear selection
Do you currently have self care practises in place regularly? For example. Journalling, Mindfulness, Breath work, Hot Baths.
Yes
No
Sometimes
Clear selection
Thank you and we can't wait to connect with you soon.
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