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1. Health and Wellness Pre-Screening Questionnaire
Whew! That's a long name. Thankfully it's longer than this form -- don't worry. There's no trick questions. Just do your best and let's get to gettin!
26
Questions
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1
New Client Information
*
This field is required.
Please enter your first and last name, email address, and best phone number to reach you.
First Name
Last Name
Email Address
Phone Number
Height
Weight (in pounds)
Date of Birth
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2
Have you ever been treated for, diagnosed as having, or currently experiencing any of the following:
*
This field is required.
Diabetes
High Cholesterol
Skin tumors, skin cancer or melanoma
Cancer
Any infectious progressive illness, such as Hepatitis B, Acquired Immune Deficiency
Syndrome or other conditions
Physical Therapy
Any circulatory disorder
Neuromuscular/neurological disorders such as seizures
Fainting, convulsions, recurrent headaches, dizziness
Stroke
Nervous or mental disorder
Active rheumatoid arthritis
Osteoporosis
Anti-coagulant medication
Anti-depressive medication
Hormonal treatment / Therapy
Liposuction or cosmetic surgery within the last six months
Allergies
Digestive problems
Laxatives or Diuretics
Smoking
Pregnancy
None / Not applicable
Other
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3
Are you currently taking any medications / drugs that may interfere with your ability to perform rigorous exercise?
*
This field is required.
YES
NO
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4
Have you ever had heart trouble or coronary disease?
*
This field is required.
YES
NO
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5
Has your doctor / cardiologist cleared you for exercise?
YES
NO
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6
Please list any injuries and/or surgeries within the last 3 years that may interfere with your ability to perform rigorous exercise:
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7
Please select the date of your most recent physical:
*
This field is required.
-
Date
Month
Day
Year
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8
How many hours of sleep do you average per night?
*
This field is required.
Please select from the list below:
1 - 4 hours
5 - 7 hours
8 hours
9+ hours
1 - 4 hours
5 - 7 hours
8 hours
9+ hours
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9
How many cups of water do you drink per day?
*
This field is required.
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10
How many cups of caffeinated beverages do you drink per day?
*
This field is required.
(Soda, coffee, tea, etc.)
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11
Have you ever participated in a diet and/or nutrition program or worked out consistently?
*
This field is required.
YES
NO
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12
Did you achieve your goal(s)?
*
This field is required.
YES
NO
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13
Did you maintain your goal(s)?
*
This field is required.
YES
NO
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14
Have you ever had a personal trainer before?
*
This field is required.
YES
NO
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15
What did you like most about working with them?
*
This field is required.
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16
What did you like least about working with them?
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17
Have you ever had a bad experience with a physical activity? If yes, please explain:
*
This field is required.
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18
Are you currently exercising regularly (at least 3x per week)?
*
This field is required.
YES
NO
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19
Please rate your exercise intensity level on a scale of 1 – 5:
*
This field is required.
(How hard do you push yourself during workouts. 1 minimal intensity to 5 the most intense)
1 - I don't break a sweat (on purpose)
2 - Jogging while reading my favorite book
3 - Yoga + Zumba (but only on the weekends)
4 - No pain. No gain.
5 - Hulk out (no roids tho)
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20
Rate yourself on the following scales:
*
This field is required.
1 - Poor
2 - Decent
3 - Average
4 - Excellent
5 - Perfect
Athletic Ability
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Competitiveness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Cardio Conditioning
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Muscular Conditioning
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Flexibility
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Athletic Ability
Competitiveness
Cardio Conditioning
Muscular Conditioning
Flexibility
1 - Poor
Row 0, Column 0
2 - Decent
Row 0, Column 1
3 - Average
Row 0, Column 2
4 - Excellent
Row 0, Column 3
5 - Perfect
Row 0, Column 4
1 - Poor
Row 1, Column 0
2 - Decent
Row 1, Column 1
3 - Average
Row 1, Column 2
4 - Excellent
Row 1, Column 3
5 - Perfect
Row 1, Column 4
1 - Poor
Row 2, Column 0
2 - Decent
Row 2, Column 1
3 - Average
Row 2, Column 2
4 - Excellent
Row 2, Column 3
5 - Perfect
Row 2, Column 4
1 - Poor
Row 3, Column 0
2 - Decent
Row 3, Column 1
3 - Average
Row 3, Column 2
4 - Excellent
Row 3, Column 3
5 - Perfect
Row 3, Column 4
1 - Poor
Row 4, Column 0
2 - Decent
Row 4, Column 1
3 - Average
Row 4, Column 2
4 - Excellent
Row 4, Column 3
5 - Perfect
Row 4, Column 4
1
of 5
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21
Please rate your readiness for change:
*
This field is required.
I need change, now.
I'm ready, but hesitant.
I'm somewhat ready.
I'm not at all ready.
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22
Please rate the following goals from 1 (least important) to 5 (most important):
*
This field is required.
1 - Least
2
3
4
5 - Most
Improve cardiovascular fitness
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Body-fat weight loss
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Reshape or tone my body
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Build more muscle
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Improve flexibility
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Increase strength
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Increase energy level
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Improve performance for a specific sport
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Improve mood and ability to cope with stress
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Feel better/improved health
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Enjoyment
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Improve cardiovascular fitness
Body-fat weight loss
Reshape or tone my body
Build more muscle
Improve flexibility
Increase strength
Increase energy level
Improve performance for a specific sport
Improve mood and ability to cope with stress
Feel better/improved health
Enjoyment
1 - Least
Row 0, Column 0
2
Row 0, Column 1
3
Row 0, Column 2
4
Row 0, Column 3
5 - Most
Row 0, Column 4
1 - Least
Row 1, Column 0
2
Row 1, Column 1
3
Row 1, Column 2
4
Row 1, Column 3
5 - Most
Row 1, Column 4
1 - Least
Row 2, Column 0
2
Row 2, Column 1
3
Row 2, Column 2
4
Row 2, Column 3
5 - Most
Row 2, Column 4
1 - Least
Row 3, Column 0
2
Row 3, Column 1
3
Row 3, Column 2
4
Row 3, Column 3
5 - Most
Row 3, Column 4
1 - Least
Row 4, Column 0
2
Row 4, Column 1
3
Row 4, Column 2
4
Row 4, Column 3
5 - Most
Row 4, Column 4
1 - Least
Row 5, Column 0
2
Row 5, Column 1
3
Row 5, Column 2
4
Row 5, Column 3
5 - Most
Row 5, Column 4
1 - Least
Row 6, Column 0
2
Row 6, Column 1
3
Row 6, Column 2
4
Row 6, Column 3
5 - Most
Row 6, Column 4
1 - Least
Row 7, Column 0
2
Row 7, Column 1
3
Row 7, Column 2
4
Row 7, Column 3
5 - Most
Row 7, Column 4
1 - Least
Row 8, Column 0
2
Row 8, Column 1
3
Row 8, Column 2
4
Row 8, Column 3
5 - Most
Row 8, Column 4
1 - Least
Row 9, Column 0
2
Row 9, Column 1
3
Row 9, Column 2
4
Row 9, Column 3
5 - Most
Row 9, Column 4
1 - Least
Row 10, Column 0
2
Row 10, Column 1
3
Row 10, Column 2
4
Row 10, Column 3
5 - Most
Row 10, Column 4
1
of 11
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23
Timeline for achieving your goal:
*
This field is required.
6 Weeks
12 Weeks
18 Weeks
24 Weeks
30 Weeks
1 Year or more
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24
How many times are you willing to train per week?
*
This field is required.
1
2
3
4+
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25
At what times during the day would you prefer to train?
*
This field is required.
Crack of Dawn (before sun up)
Normal Waking Hours (8am - 10am)
College Kid (11am - 1pm)
Hangover Hours (2pm - 4pm)
Dinner Time (5pm - 7pm)
Kids Bedtime (8pm - 10pm)
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26
Please list any equipment you own:
*
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