Customer questionnaire 2

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Please answer as many of the questions as possible, if you do not want to answer anything please leave it blank.

Part 2, contact details, Health, Lifestyle and Current fitness

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Name of emergency contact *

First

Last

Emergency contact Phone Number *

Emergency contact email *

Health

Has your doctor ever said that you have a heart condition or recommended that you should only do physical activity while supervised? *

Yes No

Do you ever have frequent pains in your chest when you perform physical activity? *

Yes No

Have you had chest pain when you were not doing physical activity? *

Yes No

Do you lose your balance due to dizziness or do you ever lose consciousness? *

Yes No

Do you have a bone, joint, or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program? * *

Yes No

If applicable: Are you pregnant now or have given birth within the last 6 months? *

Have you had a recent surgery? *

Yes No

Elaborate any questions to which you replied YES: *

Do you take any medications, either prescription or non-prescription, on a regular basis? If yes, what is it for? *

How does this medication affect your ability to exercise or achieve your fitness goals? *

Lifestyle

Do you drink alcohol (and how much?) *

Do you smoke (and how much?) *

How many hours do you sleep per night? *

What are your biggest sources of stress? *

Is you job *

Does your job require travel? How long is the commute? *

Were you overweight as a child? *

Yes No

Is anyone in your family overweight? *

When did you first start thinking about getting in shape? *

Fitness/Activity

When were you in the best shape of your life? *

Have you been exercising consistently for the past 3 months? *

For how long have you been physically active? *

How often do you take part in physical exercise per week? *

If your participation is lower than you would like it to be, what are the reasons? *

What activities are you presently involved in, and how often? (Cardio, strength training, stretching, etc.) *

On a scale of 1-10, how would you rate your present fitness level (1=worst 10=best)? *

Realistically how often per week would you like to exercise? *

How much time per session? *

Where are you likely to do your workouts? *

What kind of help do you want from your personal trainer? *

Nutrition

On a scale of 1-10 how would you rate your nutrition (1=very poor 10=excellent)? *

How many times a day do you eat? Including snacks? *

Do you skip meals? *

Yes No Occasionally

Do you eat late at night? *

Yes No Occasionally

What activities do you engage in while eating? *

How many glasses of water do you consume daily? *

Do you feel drops in your energy throughout the day? When? *

Do you know how many calories you eat per day? How many? *

Are you currently taking multivitamin or other food supplements? Which? *

At work or school, do you usually eat out or do you bring your own food? *

Do you do your own cooking? *

Besides hunger, what other reasons do you eat? *

Boredom Social Stressed Tired Depressed Happy Nervous

Do you eat past the point of fullness? *

Do you eat foods high in fat and sugar? *

Would you like nutritional coaching? *

Yes No Maybe

What specific areas of nutrition do you want to know about? *

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Home
ONLINE COACHING
Massage
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