Lifestyle Questionnaire

LIFESTYLE QUESTIONNAIRE
Please fill out this form providing me with as much information as possible so I can help you.

If you have any questions, ask for me assistance.
Name
Email
example@example.com
DOB

DayMonthYear
Date
Phone Number

Area CodePhone Number
Please let me know when is a good time to call you by making an "Appointment" below. I'll be in touch within the next 48 hours. (Unless already booked)
Physical Activity
1. Have you ever had an online coach before?
2. What sport/activity or exercise plan has worked for you in the past?
3. What type of exercise do you enjoy and where do you go to take exercise?
4. What form of sport or exercise do you dislike and why?
Occupation / Leisure
5. What is your present occupation and is it full time?
6. Does your occupation involve much physica exercise i.e. lifting,
Stress & Sleep
7. What exercise or hobbies do you like to do in your spare time?
8. Rate your quality of sleep on a scale of 1 – 10. 1 poor and 10 extremely good.
9. How important to you is a good nights sleep?
10. Rate yourself on a scale of 1 – 10. 1 being calm 10 super stressed out.
11. What situations make you feel stressed?
12. How do you calm down & relax?
Diet
13. Do you think you eat a healthy diet?
14. Do you eat 3 meals a day?
15. Do you snack in between meals and if so what do you have?
16. Do you think you eat more than you need?
17. How many calories do you think you consume in a day? Have you ever tracked your calories and macros?
18. How many litres of water do you drink in a day?
Weight
19. Do you consider yourself overweight or a healthy weight?
20. If you answered overweight, how much would you like to loose?
21. Is the rate at which you loose weight important to you?
Fitness
22. Rate yourself on a scale of 1 – 10 as to how fit you think you are
23. Rate your stamina on a scale of 1 - 10
24. How strong do you think you are?
25. How flexible do you think you are?
26. How co-ordinated do you think you are?
27. How much time will you have to do exercise?
SMART Goals

Specific, Measurable, Achievable, Relevant, and Time-Bound
28. What do you want exercise to do for you in the next

e.g. You would like to loose half a stone in the next 4 weeks, you would like to double your deadlift weight in the next 12 weeks.
1 month
Please provide details not just ‘loose weight’ etc
3 months
1 year
29. Rate your goals in undertaking exercise 1 - 10. 1= not important 10= extremely important
30. Rate in your view, the following in importance 1 – 10.
a. Improve overall health
b. Improve your fitness
C. Reshape or tone my body
D. Improve my performance for a particular sport
E. Improve mood and stress levels
Equipment
What equipment do you have available at home?
Are you a member of a gym?
Are you wanting gym or home based workouts?

LIFESTYLE QUESTIONNAIRE

Physical Activity

Occupation / Leisure

Stress & Sleep

Diet

Weight

Fitness

SMART Goals

Equipment