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First Responder - Intake Questionairre
Fill out this form prior to your Assessment Discovery Call
51
Questions
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1
What is your first and last name
Use the name that is associated with your billing. Please additionally include preferred name.
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2
What is your Whats App number
Area Code
Phone Number
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3
What is your date of birth?
Month/Day/Year
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4
What is your email address?
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5
What is your height
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6
How many hours per week do you have available to focus on yourself
including gym time, self care routines, walks etc.
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7
How would you describe your current activity level including your job?
Sedentary
Moderately Active (workout 1-3x per week and or daily walking)
Active (workout more than 3x per week but sedentary job)
Highly Active (physically demanding job + workout 3-5x per week
Only Walk
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8
Have you ever had a personal trainer or coach?
If yes, please describe your experience and list and negative or positive aspects.
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9
How long have you been training/exercising?
never trained
a few months
1-5 years
5-10 years
10 + years
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10
How long do your sessions usually last?
If its different for each element please list for each.
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11
What style of gym do you train at?
Commercial Globo Gym
Home gym
Sport/Functional Style Gym
Other
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12
What time of day do you normally train?
Morning
Afternoon
Evening
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13
Do you currently participate in any sports?
Y
N
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14
What is your number 1 goal you want to achieve first in this program?
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15
How many hours per night do you sleep on average? Do you sleep through the night? What time do you go to bed at / wake up at?
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16
Do you nap?
what is the frequency and duration typically of the nap?
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17
Do you get a second wind in the evening?
Meaning do you feel tired getting home from work, or just after dinner and then right before bed you seemingly get a burst of energy
Y
N
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18
Which blood type are you?
O+
O-
A+
A-
B+
B-
AB+
AB-
Unknown
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19
Have you ever had a nutrition consultation?
Y
N
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20
Are you currently following a specific diet or meal plan?
If yes, please describe in as much detail as possible.
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21
How would you rate your current eating habits?
Terrible
Up and down
Great
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22
Do you avoid any particular foods?
if yes please list them with the reasons why.
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23
What time of the day do you usually eat the biggest meal?
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24
How many meals do you eat out per week?
0-1
1-3
3-5
>5 meals per week
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25
Who does the grocery shopping in your household?
You
Someone else
Always eat out
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26
If you snack or have weaker moments with bad foods what do you typically eat? Include what time you generally get these cravings.
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27
How many ounces of water do you drink per day?
1 bottle of water is 17ounces
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28
How many units of alcohol do you drink per week?
Be as specific as possilbe for example. Your drink 6 beers per week include the brand. If you can also be descriptive in how these drinks are distributed. If you have 1 beer per day for 6 days. Or is that 6 in one night.
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29
Do you currently take any supplements?
If yes, please list below
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30
If currently still in school for First Responder program what is the date of your testing?
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31
Current Body Fat%
if unsure or not comfortable finding out what that number is for personal reasons please ignore this question)
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32
Do you have a goal Body Fat Percentage?
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33
Current Weight
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34
Highest adult weight
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35
How often do you weigh yourself?
Daily
Weekly
Monthly
Rarely
Only when asked
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36
Do you get weight fluctuations 5-9lbs?
Y
N
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37
Desired weight range (+/- 2lbs)
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38
What are your most important health concerns?
List in order of importance
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39
Please list all Medical diagnoses & Injury history that are relevant and would need to be considered for your training & nutrition program
Ex). Sprained ankle 5 years ago, Surgeries, IBS, Diabetes etc.
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40
Please list all medications
(including laxatives, appetite suppressants, tranquilizers, pain relievers, antacids, sleeping aids, birth control, cortisone, Marijuana, CBD etc)
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41
Please list all surgeries/hospitalizations/injuries
childbirth, minor surgeries, emergencies, even old injuries could be of relevance so include as much detail as you can.
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42
Please list all therapies you are using
(massage, accupuncture, physical therapy, rehab etc)
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43
Please list all allergies, sensitivities to drugs and or other substances
including food, environment, chemicals, dust, mold, etc)
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44
Did you eat a lot of sugar as a kid?
Even if not a “candy” kid, did you drink a lot of juice, cereal etc.
Y
N
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45
In your opinion, which lifestyle change do you think you could make that would have the biggest positive impact on your professional career?
If you haven’t started your career as a first responder you can answer in regards to what lifestyle change would have the biggest impact on your upcoming testing.
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46
What type of first responder are you?
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47
What do you feel is your biggest weakness holding you back as a first responder in regards to your health and wellness?
If still training for a test, what is your biggest concern or limiting factor leading into the test that you would like to improve on?
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48
How do you handle feedback? Do you prefer positive reinforcement or tough love as a motivational component?
Do you find advice and criticism motivating or does it cause you to dwell, overthink or have negative emotions associated with it? Or does that blunt style light a fire inside?
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49
If you are still training for your First Responder testing could you provide a detailed description of what the testing components are?
If you have a detailed document available that you could email instead of having to rewrite it all feel free to send that to this email instead: themodeltrainer22@gmail.com
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50
Which of the following equipment will you have access to?
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51
Do any of the following eating habits apply to you?
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