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Fernandes Fit Program Questionnaire
1
Name
*
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First Name
Last Name
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2
Date of Birth
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-
Month
Day
Year
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3
Phone number
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4
E-mail
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5
Height
*
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Feet-Inches
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6
Weight
*
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Pounds or Kilograms
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7
Ideal Weight
*
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Pounds or Kilograms
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8
What are your health and fitness goals? (Select all that apply)
*
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Lose weight
Live a healthier lifestyle
Tone & define your body
Increase strength
Increase muscle mass
Increase cardiovascular endurance
Other
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9
Share 2-3 reasons why these goals are important to you. Explain why.
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10
What is your time frame for reaching your goals?
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1-3 months
4-6 months
7-9 months
10-12 months
12+ months
I don't know
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11
Why is now the right time for you to pursue improving your health and fitness?
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12
Name 2-3 challenges and/or struggles you face that have kept you from achieving your goals.
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13
What are the biggest fears holding you back from achieving your goals, and why?
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14
How would you describe your experience level with health and fitness training?
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Novice (no experience)
Beginner (some experience)
Intermediate (I train but not sure what to do)
Advanced (I train and know what to do)
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15
How would you describe your level of activity on an average day?
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Sedentary (sit at a desk all day)
Lightly active (on my feet most of the day)
Moderately active (job elevates heart rate)
Physically active (physically demanding job)
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16
Where will you train?
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At home
In a public gym
Both
I travel for work and may need hotel workouts
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17
What physical activities do you enjoy and dislike, and why?
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18
Do any physical activities cause you pain and/or discomfort, and why?
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19
What non-physical activities do you enjoy, and why?
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20
Do you believe your current eating habits are healthy? Why or why not?
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21
What nutritional plans have you followed in the past? Why did you choose those plans, and did they achieve the desired results?
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22
Rate your average daily stress level? (1 - no stress at all, 10 - extremely stressed all the time)
*
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1
2
3
4
5
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7
8
9
10
1
2
3
4
5
6
7
8
9
10
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23
What factors cause you the most stress, and why?
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24
How many hours of sleep do you get on an average night?
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Less than 4
5-6
7-8
9 or more
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25
Rate your average night's sleep? (1 - no sleep at all, 10 - great night's sleep every time)
*
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1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
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26
What factors affect your quality of sleep, and why?
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