Smile With Movement Intake Questionnaire

Smile With Movement

Health, Nutrition, and Fitness Questionnaire
Name*

First NameLast Name
Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Height *
Current Weight *
Goal Weight *
Health Goals

Answer all questions honestly.
Please describe your major health, nutritions and/or fitness goals. *
What are 2-3 barriers keeping your from these goals? *
What are 2-3 strengths that will help you achieve these goals? *
What following goals fits best with your goals? Select all that apply.*

Improved healthImproved enduranceIncreased strengthIncrease muscle massFat lossFeel sexy
How important is the number on the scale to you?*

Very importantNot at all importantIndifferent
Rate you readiness to change?*

1

2

3

4

5

1 is Not Ready, 5 is Ready!
Do you have a good support system?*

YesNo
Medical Information

Please answer all questions honestly.
How would you describe your overall health?*

ExcellentGoodFairPoor
Please list any current/past injuries?*
Are you taking any prescriptions, over-the-counter medication, or supplements?*

YesNo
If you answered yes to above please list. If you answered no please put NA.
Do you have any health issues or concerns that you want to let me know of? *
Physical Activity History
Are you currently physically active?*

YesNo
* number of mins of cardio *per week.

Type a label* number of mins of resistance/strength training   Type a label* per week.

  *  number of mins of flexibility training   *  per week.
Please list your favorite physical activities.
Anything else you want me to know? *
Should be Empty:

Smile With Movement

Health Goals

Medical Information

Physical Activity History