Kaizen Health & Fitness: New Client Questionnaire

1
Are you a minor, or are you the parent or legal guardian submitting this on behalf of a minor under the age of 18?* This field is required.
YESNO
2
Parent/Legal Guardian Name
First Name
Last Name
3
Parent/Legal Guardian Email
example@example.com
4
Parent/Legal Guardian Phone Number
Area Code
Phone Number
5
Name* This field is required.
First Name
Last Name
6
Email
example@example.com
7
Phone Number
Area Code
Phone Number
8
What is your age? * This field is required.
9
Height & current weight (if known)
10
Would you like to share your gender & preferred pronouns? List them below.
11
Which coaching services are you interested in pursuing?* This field is required.Select all that apply
Please Select
In-Person Training
Remote Live Training
Online Programming
Unsure
12
Where will you be training?Select all that apply
Please Select
Own Home Gym
Kaizen Health & Fitness Studio
Commercial Gym
College Gym
College Athlete Gym
Outdoors
Other
Select all the locations that apply
If you selected other, please describe the set up.
13
How many workouts per program are you interested in?Choose a realistic number over an ideal number
1
2
3
14
How many hours, on average, of sleep do you get per night?* This field is required.
15
Do you currently experience any regular (weekly or more) pain, aches, or physical discomfort?
YESNO
16
What is the highest this pain, discomfort or aching gets on a scale of 1-10? 1 = barely noticeable; 10 = worst pain you have ever felt
1 (mild)
2
3
4
5
6
7
8
9
10 (worst)
Rating
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Rating
1 (mild)
Row 0, Column 0
2
Row 0, Column 1
3
Row 0, Column 2
4
Row 0, Column 3
5
Row 0, Column 4
6
Row 0, Column 5
7
Row 0, Column 6
8
Row 0, Column 7
9
Row 0, Column 8
10 (worst)
Row 0, Column 9
17
Please describe any neurological or musculoskeletal conditions you have been diagnosed with, and any past or present injuries.* This field is required.Including but not limited to conditions such as: chronic or acute pain or discomfort of your joints or muscles, tendonitis, muscular, ligament, or tendon tears, osteopenia, osteoporosis, MS, ALS, Parkinson's Disease, sprained ankles, surgeries, tendonitis, etc.
18
Please list any medical conditions you have been diagnosed with that would affect your lymphatic, GI, circulatory, or pulmonary systems, including conditions that affect the heart, lungs, blood vessels, digestion, brain, etc. * This field is required.Such as heart disease, high cholesterol, diabetes/insulin resistance, high or low blood pressure, Chrone's Disease, cancer, lymphedema, etc.
Huge
Large
Normal
Small
Ok
Ok
19
Please list any medical conditions, including medications, that would affect your response to changes in eating or exercises?
20
Have you ever done any kind of strength training before?* This field is required.
Yes
No
21
How many total years of experience do you have strength training?
0-1
1-3
3+
22
Please list or describe your experience with exercise in general, including different modalities that you enjoy:* This field is required.
23
Please list any physical activities and sport/s you participate in:
For example: strength training 1-2x/week for 60 mins, walking 30 min 1x/week, pickup basketball once a month
24
Please check off any exercise equipment you have access to:* This field is required.
Mini-bands (short loop)
Long super bands (long loop)
Therabands (physical therapy bands)
Resistance band tubes w/ handles
Pole or study object to anchor bands
Door anchor for bands
Dumbbells
Kettlebells
Barbell
Body bar
Medicine Ball
Slam ball
Stability ball (large, bouncy, air filled)
Cable or pulley
Weight plates
Step or plyo box
Adjustable bench
Flat bench
Battle rope
TRX or suspension trainer (includes rings)
Heavy or speed bag
Sandbags
Pull-up bar
Strength machines
Squat rack
Landmine
Weighted vest or backpack
Treadmill
Elliptical
Stationary bike
Recumbent bike
Rower
Jump rope
Sanddune
Slider discs
Yoga blocks
Foam roller
Yoga mat
Yoga strap
Sand disc
Backpack
Safe outdoor walking routes or trails
Other
25
What would you most like to get out of an exercise program in order of importance?* This field is required.This is includes your goals, needs & how you'd like the time to be spent
26
Is there anything else you'd like me to know?
27
How did you hear about me? * This field is required.
28
You made it!

After you hit submit below, I'll reach out via email within 48 business hours to schedule your free virtual 15-minute consultation. Go ahead, hit that Submit button below!
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