Health Audit Questionnaire

1
Audit Bundle
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
BUNDLE - Nutrition and Fitness$50 Savings
$299.00Edit
Back
Enter Coupon
Total cost $0.00
Audit Bundle
loading smart payment buttons...
The payment is ready! It will be completed once you submit the form.
2
3
CONTACT INFORMATION* This field is required.
First Name
Last Name
Email
Phone
9am - 11am
Please Select
9am - 11am
11am - 1pm
1pm - 3pm
3pm - 5pm
5pm - 7pm
Best Contact Time
N/A
Please Select
N/A
Facebook
Google
LinkedIn
Instagram
Family/Friend
Client
School Event
Team Event
Mailing
Flyer / Postcard
Referred by
4
MAILING ADDRESS* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Health History Information* This field is required.
DOB: MM/DD/YYYY
Age
Please Select
Please Select
Male
Female
Other
Prefer not to answer
Gender
Current Height (in)
Current Weight (lbs)
Desired Weight (lbs)
6
Any major fluctuations in weight in the past 12 months (+ or )?* This field is required.
YESNO
7
Did your physician recommend that you lose weight and/or start an exercise program?* This field is required.
YESNO
8
Are you taking any OTC or prescription drugs on a regular basis?
No
Please Select
Yes
No
Currently taking OTC or Rx?
If yes, please list meds, dose(s) and reason(s)
9
Are you taking any supplements or multi vitamins?* This field is required.
No
Please Select
Yes
No
Currently taking supplements/vitamins?
If yes, please list
10
Are you currently (or during the past 2 years) seeing a chiropractor, physiotherapist, massage therapist, occupational therapist, or any other health therapist?* This field is required.
No
Please Select
Yes
No
Currently seeing therapist?
If yes, please provider type
11
Do you now, or have you had in the past ANY of the following condition?* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
History of heart problems, chest pain, or stroke
Increased blood pressure (hypertension) or low blood pressure Any chronic illness or condition (cancer, MS, epilepsy, fibromyalgia)
Difficulty with physical exercise
Advice from a physician not to exercise
Recent surgery in the past 24 months
Pregnancy (now or within the last 12 months)
Breastfeeding (now or within the last 12 months)History of breathing/lung programs (asthma, COPD, emphysema)
Muscle, ligament, tendon, joint (shoulder, knee, hip, ankle, wrist) neck, or back disorder/injury or any previous injury still affecting you
Arthritis, Rheumatoid arthritis, osteoporosis
Diabetes (type I or II), a thyroid condition, or hypo/hyperglycemia
Cigarette smoking habit
Obesity (more than 20 percent over ideal weight)
Increased blood cholesterol
History of heart problems or other conditions in immediate family
Hernia or any condition that may be aggravated by lifting weights
Frequent headaches (migraine, cluster, stress/tension)
Frequent colds, flu, upper respiratory infection, strep throat
Mental health conditions (depression, bipolar, etc)
Circulatory problems/conditions
Stomach, intestinal, digestive problems/conditions
History of heart problems, chest pain, or stroke
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 20
12
Are you now or have you been on any kind of weight loss program (diet) or nutritional program in the past ?
Please Select
Please Select
Yes
No
If yes, please provide details
13
Do you eat breakfast regularly?* This field is required.
YESNO
14
How many meals, including snacks do you eat in a typical day?* This field is required.
1-2
3-4
5-6
7+
15
How soon after waking do you eat?* This field is required.
16
What is generally your largest meal of the day?* This field is required.
Largest meal of the day
17
How long after your last meal do you go to sleep? * This field is required.
Hours after last meal
18
How many times a weeks do you eat out each week?* This field is required.
1
2-3
4+
19
How much do you spend on restaurant/cafe style food each week?* This field is required.
$0
$1 - 50
$51 - 100
$100+
20
How many ounces of water do you drink per day?* This field is required.
< 60
60 - 80
80 - 100
100 - 120
120+
21
What would you estimate to be your average caloric intake?* This field is required.
Don't know
< 1000
1000 - 1500
1500 - 2000
2000 - 2500
2500 - 3000
3000+
22
Do you eat late at night?
YESNO
23
What activities do you engage in while eating?* This field is required.
Activities while eating
24
Do you consume any other beverages than water? If Yes, what do you consume?* This field is required.
Yes
Please Select
Yes
No
Beverages other than water
Non-water beverages
25
Do you consume caffeine?* This field is required.
YESNO
26
Do you know your daily caloric intake? If so, please provide
No
Please Select
Yes
No
Please list caloric intake
27
What foods do you regularly eat?* This field is required.
Food you eat
28
Do you eat past the point of fullness?* This field is required.
YESNO
29
Do you do your own cooking?* This field is required.
YESNO
30
Do you do your own cooking? If not, how does?* This field is required.
Yes
Please Select
Yes
No
Do you cook?
If not, who cooks?
31
Besides hunger, what reasons do you eat? (Check all that apply)
Bored
Social
Stressed
Tired
Depressed
Happy
32
Do you read nutrition labels? If yes, what nutrition labels do you look at?
No
Please Select
Yes
No
Labels viewed
33
Do you have a goal weight or goal body fat percentage? If yes, please list.
Please Select
Please Select
Yes
No
Goal weight/fat%
34
Have you ever been diagnosed with an eating disorder?* This field is required.
YESNO
35
Do you currently exercise?* This field is required.
YESNO
36
Can you exercise during your workday; before, during, or after? (Check all that apply)
No
Yes, Before
Yes, During
Yes, After
37
What is your current occupation and does it require much activity (i.e. walking, stairs, carrying)?
Please Select
Please Select
Yes
No
38
What areas of your life seem to cause you the most stress? (Check all that apply)* This field is required.
Work
Home/Family
Education
Finances
Health
Social
39
Do you drink alcohol? If yes, how much per week?
Yes
Please Select
Yes
No
40
What is your stress level on a daily basis (1 = low/no 5 = high)* This field is required.
1
2
3
4
5
41
How do you normally deal with stress?
Huge
Large
Normal
Small
Ok
Ok
42
How many hours of sleep do you get each night? Is it restful?* This field is required.
Hours
Please Select
Please Select
Yes
No
Is it restful?
43
What are your personal barriers to exercise (i.e. your reasons for not exercising)?
Huge
Large
Normal
Small
Ok
Ok
44
How much of a priority is it for you to achieve results?* This field is required.
Not at all
Fairly Important
Important
Very Important
45
How many times a week can you work out and how long? * This field is required.
Please Select
Please Select
1 - 2
3 - 4
5+
Workout frequency
Please Select
Please Select
30 min
60 min
Other
Workout duration
46
Is there a significant other or close friend/family member to support your efforts in achieving your personal fitness goals?
YESNO
47
Have you ever worked with a heath/wellness/fitness coach?* This field is required.
YESNO
48
Rank your goals in starting an exercise program. Use the following scale to rate each goal:* This field is required.1 = Not Important --> 3 = Somewhat Important --> 5 = Extremely Important
5
4
3
2
1
Improved cardiovascular fitness
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Reshape or tone body
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Build muscle
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Improved flexibility
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Improved sport performance
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Improved mood & stress management
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Increased energy level
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Fell better, positive attitude
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Ensure workouts are fun
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Exercise safely and with proper form
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
maintain workout consistency
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Improved cardiovascular fitness
Reshape or tone body
Build muscle
Improved flexibility
Improved sport performance
Improved mood & stress management
Increased energy level
Fell better, positive attitude
Ensure workouts are fun
Exercise safely and with proper form
maintain workout consistency
5
Row 0, Column 0
4
Row 0, Column 1
3
Row 0, Column 2
2
Row 0, Column 3
1
Row 0, Column 4
5
Row 1, Column 0
4
Row 1, Column 1
3
Row 1, Column 2
2
Row 1, Column 3
1
Row 1, Column 4
5
Row 2, Column 0
4
Row 2, Column 1
3
Row 2, Column 2
2
Row 2, Column 3
1
Row 2, Column 4
5
Row 3, Column 0
4
Row 3, Column 1
3
Row 3, Column 2
2
Row 3, Column 3
1
Row 3, Column 4
5
Row 4, Column 0
4
Row 4, Column 1
3
Row 4, Column 2
2
Row 4, Column 3
1
Row 4, Column 4
5
Row 5, Column 0
4
Row 5, Column 1
3
Row 5, Column 2
2
Row 5, Column 3
1
Row 5, Column 4
5
Row 6, Column 0
4
Row 6, Column 1
3
Row 6, Column 2
2
Row 6, Column 3
1
Row 6, Column 4
5
Row 7, Column 0
4
Row 7, Column 1
3
Row 7, Column 2
2
Row 7, Column 3
1
Row 7, Column 4
5
Row 8, Column 0
4
Row 8, Column 1
3
Row 8, Column 2
2
Row 8, Column 3
1
Row 8, Column 4
5
Row 9, Column 0
4
Row 9, Column 1
3
Row 9, Column 2
2
Row 9, Column 3
1
Row 9, Column 4
5
Row 10, Column 0
4
Row 10, Column 1
3
Row 10, Column 2
2
Row 10, Column 3
1
Row 10, Column 4
1 of 11
49
List in order of priority the 1-3 goals you would like to achieve in the next 3-6 months.
Huge
Large
Normal
Small
Ok
Ok
50
What do you think you will need to do in order to successfully reach this goal?
Huge
Large
Normal
Small
Ok
Ok
51
What do you think your biggest challenge will be in meeting your fitness goal?
Huge
Large
Normal
Small
Ok
Ok
52
What is the number one thing you are hoping to learn from your Coach?
Huge
Large
Normal
Small
Ok
Ok
53
Waiver & Release of Liability* This field is required.I have volunteered to participate in physical training under the direction of Go Good Guru. which will include, but may not be limited to, weight and/or resistance training.  In consideration of the Go Good Guru. agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Go Good Guru., and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting therefrom.  THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES THAT MAY OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT, AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION. 
54
Assumption of Risk* This field is required.I have volunteered to participate in physical training under the direction of Go Good Guru. which will include, but may not be limited to, weight and/or resistance training.  In consideration of the Go Good Guru. agreement to instruct, assist, and train me, I do here and forever release and discharge and hereby hold harmless Go Good Guru., and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting therefrom.  THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES THAT MAY OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT, AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION. 
55
Please verify that you are human* This field is required.
56
Invoice ID
Should be Empty: