Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO. 

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction

Clients goals

1.What’s bought you to see us today? What is your goal

 

2.Have you tried to achieve this goal before?

 

3.If yes, what has stopped you from achieving this goal before?

 

4.How long have you been trying to achieve this goal?

 

5.Have you set a time Frame for this goal?

 

6. On a scale of 1-10 how important is it to achieve your goal? 
1- Being not very important -10 being the most important thing “ I will stop
at nothing to achieve this goal

 

7. Do you have the support of your family and friends?

 

 

8. How soon would you like to start working towards this goal?

 

 

9. Is there an event that will help motivate you towards this goal?

 

10. What is your exercise History, if any?

 

11. On a scale of 1-10 how would you rate your exercise, nutrition and supplement knowledge?

 

12. What would you most like to learn in relation to the above?


 

13. On a scale of 1-10 how would you rate your sleep? Please describe your normal sleeping patterns

 

14. On a scale of 1-10 please describe your stress levels

 

 

15. Do you or do you have a family history of any of the following?
 Depression
 Nervousness
 Anxiety
 Extreme Anger and or aggression

If ticked any of the above please describe below

 

16. On a scale of 1-10 how would you rate your overall energy level throughout the day

 

17. On a scale of 1-10 how would you rate your libido?

 


18. Which areas would you like to see improvements?

 

19.how much time can you invest per week into achieving this goal

 

 

 

 

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING
IF YOU TICKED YES TO ANY OF THE ABOVE, it is advised you take this form to your G.P and ask for a medical clearance before commencing any exercise or dietary changes.

 

If you do not wish to have medical clearance from your G.P you may sign and date the below stating that you have chosen not to seek medical clearance.
Clients Name ________________________________________________ Date __________
Clients Signature ____________________________________________________________
Trainers Name ___________________________________________________________ 

TrainersSignature__________________________________________

PLEASE LET YOU TRAINER KNOW A.S.A.P IF ANY OF THE ABOVE INFORMATION CHANGES

I authorize Vsquarefitness to bill my credit card every last day of the month for the services provided during that month. 

NUTRITIONAL INFORMATION

 

1. Typical Breakfast

 

2. Typical Snacks

 

3. Typical Lunch

 

4. Typical Afternoon Snack

 

5. typical Dinner

 

6. Typical After Dinner Snack

 

7. Do you smoke?     If so how often?

8. Do you drink Alcohol?    If so how many units per week?

9. Do you drink caffeinated beverages? If so how many per day and at what time intervals.

 

10. What is your daily water consumption?

 

11. Do you have any food allergies / Intolerances?

 

12. Do you crave any of the following?
 Sugar
 Meat
 Fat
 Alcohol
 Bread
 Chocolate
 Desserts
 Fried Foods
 Fish
 Milk
 Other

13. Do you take any supplements or vitamins

if so please list ALL below

 

14. Are you currently taking any prescription medicine ( inc any concentrative)

15. Please check off any of the below that pertain to you past OR present
 Acne
 Diabetes 1
 Colonics
 Addiction
 Anemia
 Diabetes 2
 Liver Problems
 Memory loss
 Thyroid conditions
 Yeast Infections
 STD’s
 Diarrhea
 Anorexia
 Bladder infections
 Difficult weight loss
 Difficult Weight Gain
 Fainting
 Bloating, gas, indiges-
tion
 Blood Sugar Problems
 Hair loss or Growth
 Headaches
 Insomnia
 Skin Conditions
 Depression
 Cold sores
 Chronic Fatigue
 Constipations
 Seizures
 IBS
 Poor Nail Growth

Women Only
 PMS
 Loss of libido
 Menopause
 Children
 Hysterectomy
 Other
 Irregular Periods
 Painful Periods
 Painful Intercourse

 

Men Only
 Frequent Urination
 Erectile Difficulties
 Difficulty Urination
 Loss Of Libido

 

Please Describe Any Health Concerns you think are important
By signing below, you acknowledge that any dietary or supplementation suggestions made by your personal trainer are not intended as diagnosis, cure or treatment for any disease or injury. You also acknowledge that your Dr or G.P is your primary health care provider, and is
responsible for supervising all changes in diet and nutrient intake that you make.