Client Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Height
*
Weight
*
Age
*
What are you looking for help with?
*
Nutrition
Training
Workout Split - periodization
Competition Prep
What is your occupation?
Please Select the one that best describes your goals:
*
WEIGHT LOSS= Designed to decrease body fat with a minimal loss of lean body tissue. One will experience tighter physique by decreasing fat and water retention.
MAINTAIN WEIGHT/CHANGE BODY COMPOSITION= Designed to maintain current body weight and develop muscle density and maturity while decreasing body fat and water retention.
WEIGHT GAIN= designed to increase lean body mass (muscle) with minimal increase in body fat. Some water retention may occur after weight training in order to assist the muscles in growth.
What are some obstacles (behaviors, stress, activities, etc) that you foresee impeding your success? Have you developed any plans to overcome these obstacles?
Lifestyle
What best describes your professional activity level?
*
SEDENTARY= Sitting more than 7-8 hours during the work day.
MODERATELY ACTIVE= Sitting 6 hours and on your feet at least 2 hours during a work day.
ACTIVE= On your feet more than 5 hours during the work day.
VERY ACTIVE= On your feet more than 6 hours and doing periodic lifting during the work day.
Have you had recent blood work done?
Yes
No
Do you have any allergies you are aware of? (Food, Environmental, etc.)
If you are on any medications, please list them.
Nutritional Information
How do you monitor your eating habits?
Do you feel that you eat a healthy diet most of the time?
Yes
No
How much water do you drink per day?
Do you consume coffee?
Energy Drinks?
Do you consume alcohol?
Describe a typical day in your diet from waking until bed:
How do you feel about diets? Have you tried any "fad" diets?
Do you take supplements? If yes, please list below:
Do you have any specific cravings? If yes, for what and when?
How much sleep do you typically get?
What time do you normally wake?
When do you usually consume your first meal for the day?
Do you struggle with structure?
Yes
No
Any prior eating disorders or a form of disordered eating? If yes, please describe.
Fitness
Are you currently exercising? If so how long?
Have you begun an exercise program in the past?
Yes
No
Were you successful?
Yes
No
What if anything stopped you from continuing?
Current Regiment
Weight Training
Yes
No
Duration/Frequency
Cardiovascular
Yes
No
Duration/Frequency
Realistically, how often are you willing to exercise?
How long are you willing to spend at each exercise session?
List any other cardio/sports/activities that you are involved in:
Do you have any injuries or surgeries? Please list any details, even if you think they may not be important.
Are there any specific exercises that you are unable to perform? Please list:
Submit
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