Client Questionnaire

Personal Details
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

YearMonthDay
Date
Sex

MaleFemaleN/A
Ethnicity
How did you hear about us

Friend/FamilyFacebookInstagramInternet SearchOther
WELLNESS ASSESSMENT
Height
Weight
Desired Weight
Body Fat %
Asthma

YesNo
Chronic Cough

YesNo
Chronic Colds

YesNo
Shortness of Breath

YesNo
Chronic Fatigue

YesNo
Dizziness

YesNo
Poor Memory

YesNo
Nervous Syndrome

YesNo
Migraines

YesNo
Allergies

YesNo
Chronic Sinuses

YesNo
Vision Problems

YesNo
Blurry Vision

YesNo
Hearing Loss

YesNo
Ear Infections

YesNo
Anemic

YesNo
Anxiety

YesNo
Stress

YesNo
Depression

YesNo
Irritability

YesNo
Diabetes

YesNo
Arthritis

YesNo
High Cholesterol

YesNo
High Blood Pressure

YesNo
High Blood Pressure Number
History of Cancer

YesNo
Which kind
Kidney Disease

YesNo
Kidney Stones

YesNo
Urinary Infections

YesNo
Urinate at Night

YesNo
Swollen Feet or Hands

YesNo
Thyroid Disease

YesNo
Liver Disease

YesNo
Lung Disease

YesNo
Heart Disease

YesNo
Constipation

YesNo
Diarrhea

YesNo
Irregular Bowels

YesNo
Bloating/Burping

YesNo
Abdominal Pain

YesNo
Cravings

YesNo
Teeth Grinding

YesNo
Poor Appetite

YesNo
Lower Back Pain

YesNo
Dry Mouth

YesNo
Gallbladder Stones

YesNo
Stomach Ulcers

YesNo
Acid Reflux

YesNo
History of GERD

YesNo
Low Sex Drive

YesNo
Low Testosterone

YesNo
How many bowel movements a day
Have you had surgeries before

YesNo
Please explain
Have you taken antibiotics

YesNo
How many rounds
Are you taking prescription drugs

YesNo
Please explain
Are you taking recreational drugs

YesNo
Please explain
Do you drink alcohol

YesNo
How many times a week and amount
Do you drink caffeine

YesNo
Do you smoke

YesNo
How many a day
How many times a week and amount
Do you see a General Doctor

YesNo
When was the last time you had a physical
Do you have any nutritional restrictions given by your Doctor

YesNo
What are they
Do you have any health concerns

YesNo
Please Explain
What have you done to work on these concerns
Are you pregnant

YesNo
Have Children

YesNo
Regular Menstrual Cycle

YesNo
Birth Control

YesNo
Ovarian Cysts

YesNo
Infertility Issues

YesNo
Have you had a c-section

YesNo
Menopause

YesNo
LIFESTYLE ASSESSMENT
What time do you wake up

Hour Minutes

AM/PM Option
What time do you go to sleep

Hour Minutes

AM/PM Option
Occupation
Please rate your sleeping patterns

Bad12345678910Good
How many hours do you work a day
How many days do you work a week
What is your work schedule
How do you spend your days off
Do you read books

YesNo
How many times a week
Do you attend Church or any other group activities

YesNo
Do you meditate

YesNo
How many times a week
Do you live an active lifestyle

YesNo
What kind of activities do you participate in
Do you socialize outside of work with friends and family

YesNo
How many times a week
What practices do you follow when stress increases or after a stressful day
Do you have children

YesNo
How many days a week do you spend quality time with them
Are you married or in a relationship

YesNo
How many days a week do you spend quality time together: What kind of fun activities do you enjoy doing together
Have you worked with any of the following

NutritionistPersonal TrainerNaturopathHealth CoachAcupuncturistChiropractic
DAILY ACTIVITIES (Needs to total 24 hours)
How many hours or minutes of sleep a day?
How many hours or minutes of standing a day?
How many hours or minutes of sitting a day?
How many hours or minutes of walking a day?
How many hours or minutes of driving a day?
How many hours or minutes of cardio a day?
How many hours or minutes of HIIT/Crossfit/Lifting training a day?
How many hours of household work a day?
What is it that you want to accomplish?

Gain MuscleLose WeightImprove Physical FitnessGet StrongerHave More EnergyLook/Feel Better
TRAINING SCHEDULE
Monday
Time
Duration
Type
Tuesday
Time
Duration
Type
Wednesday
Time
Duration
Type
Thursday
Time
Duration
Type
Friday
Time
Duration
Type
Saturday
Time
Duration
Type
Sunday
Time
Duration
Type
NUTRITION ASSESSMENT
Do you eat the following
Carbohydrates

YesNo
Vegetables

YesNo
Fruits

YesNo
Animal Products

YesNo
Nuts and Seeds

YesNo
Legumes/Beans

YesNo
Healthy Fats

YesNo
Dairy

YesNo
Which kinds of cooking oil do you use

Coconut OilAvocado OilOlive OilVegetable Oil
Please list all fruits and vegetables you dislike
Please list all animal products you dislike
Please list all nuts and seeds you dislike
If you eat legumes, which are your favorite
What is your favorite Macronutrient: Pick one

ProteinCarbsFats
Have you had herbal teas before

YesNo
Please list which ones
Are you taking supplements

YesNo
Please list
What are your favorite considered junk foods or drinks
How many meals per day do you eat
How many snacks per day do you eat
What time is your first meal or snack
What time is your last meal or snack
How many oz of water do you drink daily
What other fluids do you drink daily
Please list a sample of your daily meals
Breakfast
Lunch
Dinner
Snacks
Do you get bloated after a meal

YesNo
How many times a week do you eat out
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Personal Details

WELLNESS ASSESSMENT

LIFESTYLE ASSESSMENT

DAILY ACTIVITIES (Needs to total 24 hours)

TRAINING SCHEDULE

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Please list a sample of your daily meals