Questionnaire

NAME:

AGE:

GENDER:

HEIGHT:

WEIGHT:

CELL PHONE NUMBER:

E-MAIL:

HEALTH CONDITIONS (if any, past or present):

MEDICATIONS that may affect workout:

PREVIOUS SURGERIES OR HOSPITALIZATIONS:

PHYSICAL LIMITATIONS/DISABILITIES OR INJURIES (Past or Present):

ANY DEFICIENCIES?

DO YOU HAVE ANY ACUTE PAIN? IF SO, PLEASE EXPLAIN:

DO YOU HAVE ANY CHRONIC PAIN? IF SO, PLEASE EXPLAIN:

WHAT ARE YOUR FITNESS GOALS?

WHAT IS YOUR DESIRED TIMELINE TO MEET THESE GOALS?

WHAT ARE YOUR PHYSICAL STRENGTHS?

WHAT ARE YOUR PHYSICAL WEAKNESSES?

ANY PHYSICAL AREAS YOU FEEL REQUIRE EXTRA ATTENTION?

WHAT TYPE OF PHYSICAL ACTIVITY DO YOU CURRENTLY ENGAGE IN?

HOW OFTEN DO YOU EXERCISE?

WHAT ARE YOUR PREFERRED MODES OF EXERCISE(e.g., weightlifting, cardio, yoga, etc.)?

WHAT ARE YOUR PREFERRED TIMES OF DAY TO EXERCISE?

ON A SCALE OF 1-10, RATE YOUR OVERALL FITNESS LEVEL…10 BEING THE HIGHEST:

WHERE WILL YOU WORKOUT?

ALL OTHER AVAILABLE EQUIPMENT:

DO YOU HAVE AN DIETARY RESTRICTIONS OR ALLERGIES?

HOW MANY MEALS DO YOU EAT PER DAY?

DO YOU FOLLOW ANY DIET PLANS?

ESTIMATED DAILY CALORIE INTAKE:

WHAT TIME DO YOU WAKE UP?

WHEN IS YOUR FIRST MEAL?

WHAT TIME DO YOU GO TO SLEEP?

WHAT TIME IS YOUR LAST MEAL?

FOOD LIKES:

FOOD DISLIKES:

HOW MANY HOURS OF SLEEP DO YOU TYPICALLY GET?

DO YOU SMOKE, HOW OFTEN?

DO YOU DRINK ALCOHOL, HOW OFTEN?

DO YOU HAVE JOB STRESS OR OTHER LIFE STRESSES?

DO YOU HAVE STRESS MANAGEMENT TECHNIQUES?