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Health/Fitness/Nutrition Questionnaire
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* Indicates required question
Name
*
Your answer
Phone number
*
Your answer
Email
*
Your answer
Preferred form of contact
*
Choose
Email
Phone
What do you do for a living?
*
Your answer
What is your work schedule?
*
Your answer
What is your activity level at work?
*
Sedentary (seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Other:
Tell me what your typical week looks like. (Wake up, work, come home, etc)
*
Your answer
Do you have any health conditions? Please explain
Your answer
Do you have any injuries?
Your answer
Has anyone in your immediate family developed heart disease before the age of 60?
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Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
Your answer
Are you a current cigarette smoker?
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Yes
No
Have you ever tried following diets? If so, tell me all about it.
*
Your answer
What are your current eating habits? (Types of foods, how often you’re eating, eating out, etc)
*
Your answer
How much water do you drink a day?
*
Your answer
What other types of drinks do you consume daily?
*
Your answer
Do you have any food allergies? If so, please explain. Write ‘N/A’ if none.
*
Your answer
How would you rate your lifting expertise?
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Beginner (never lifted, max 3 months before stopping)
Intermediate (6+ months, up to a year of consistent working out)
Expert (2+ years of consistent working out)
Do you currently exercise? If so, tell me what you do for exercise.
*
Your answer
How often do you exercise?
*
1-2 days/week
3-4 days/week
5+ days/week
What are you looking for from me as your coach? (Accountability, knowledge, motivation, etc)
*
Your answer
On a scale of 1 to 10, how ready are you to commit to change?
Will not change
1
2
3
4
5
6
7
8
9
10
Very ready to change
Clear selection
On a scale of 1 to 10, how motivated are you?
Zero motivation
1
2
3
4
5
6
7
8
9
10
Absolutely, completely motivated
Clear selection
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