BODY TRANSFORMATION QUESTIONNAIRE
Name
First Name
Last Name
Age
Height
Social media
Instagram/facebook
Email
example@example.com
Confirm email address
example@example.com
Phone Number
-
Area Code
Phone Number
Wieght
Goals
Improve health
Improve endurance
Improve strength
Improve muscle mass
Fat loss
Weight gain
Sports specific
Other
Please list your specific goal eg (amount of weight loss, % body fat loss, amount of lean muscle etc.)
If you have any what are the specific time frames for achieving your goals?
Please tick what type of progress is most important to you
Immediate progress that is less easy to maintain
Maintainable progress that may not be as rapid
EXERCISE HISTORY (what is your fitness/strength training experience)
Beginner
Intermediate
Experience
Do you currently train at least 3 times a week?
Yes
No
Using the keys, list which types of training you do on which days: Resistance training (RT), INTERVAL CARDIO(INT), LOW INTENSITY CARDIO (LIT), SPORT SPECIFIC WORK (SSW)
LIST DAYS FROM MONDAY-SUNDAY
If you are not already training at least 3 times a week consistently, have you ever been on a consistent exercise programme (more than 3 times a week)?
Yes
No
If you have previously exercised on a continuous basis, how long ago was this and how long did this last?
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Commitment
Are you willing to exercise for at least 5 hours per week?
Yes
No
Do you have a gym membership? If not, are you willing to get one?
Yes
No
Are you willing to spend at least 30 minutes a day preparing your meals/prepare your meals in bulk for 3 days at a time?
Yes
No
Are you willing to financially invest in yourself to get the results you want? *
YES: I understanding investing in a coach will help me reach my goal quicker
MAYBE: I am willing to invest but want to find out more about the program
NO: I don’t have the money right now
How much of a priority is achieving these goals to you?
High Priority: I need to start working on myself immediately
Low Priority: This isn’t a priority, and i’m happy to go at my own pace
What makes you think you would be a good client?
What’s made you want to chose me as your coach?
How did you hear about me?
You can upload a photo here ahead of the call for David to see your current physique
Browse Files
(pictures must be taken from front back and side behind a clear background)
Cancel
of
Medical
If you have any diagnosed health conditions, please list them below.
If you are currently on any medication(s), please list them below, this includes any contraception.
What additional therapies or interventions are currently taking place for the listed health problems?
Please list any current injuries.
Please list any previous injuries.
What therapies/ interventions are currently being undertaken for any current or previous injuries stated?
Do you smoke?
Yes
No
If the answer is yes, how many do you smoke each day?
Do you drink?
Yes
No
If yes, how many units of alcohol do you consume each week? 175ml glass of wine is 2 units, 1 pint of beer/larger is 3 units.
I don't drink
2-5 units
5-10 units
More than 10 units
I binge drink occasionally, not weekly
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Lifestyle
What do you do for a living?
What level of physical activity is required for your job?
None
Moderate
High
Does your job involve shift work?
Yes
No
If you follow a more regular working schedule, do you work mornings, days or nights?
Mornings
Days
Nights
Do you have children?
Yes
No
Please indicate any physical activity you partake in outside the gym and outside of work
How many times do you go food shopping each week?
How many times a week do you eat out (includes restaurants and takeaways)
How much money do you spend on supplements per month?
If you have any allergies, please list them below.
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Menstrual Cycle
Are your periods painful?
Yes
Sometimes
No
Do you experience clotting?
Yes
Sometimes
No
Date of your last cycle? (date it started)
Frequency?
Length?
Are you currently on contraception?
Yes
No
If yes, please indicate which form of contraception you use
If you are not currently using contraception, but have previously used hormonal forms of birth control, please indicate which type and for how long
Do you experience breast tenderness, water retention or irritability (PMS) symptoms in the second half of your cycle?
Yes
Sometimes
No
Please indicate any other symptoms you feel are significant.
Have you began or been through the menopause?
Yes
No
If yes, what age did your menopause start?
Digestion
Do you suffer from any of the following?
Indigestion or heart burn?
Yes
No
Gas or belching?
Yes
No
Constipation?
Yes
No
Diarrhoea?
Yes
No
Are there any foods that make you feel uncomfortable after eating? Please list them below.
Do you feel full after meals?
Yes
No
Do you suffer from bloating 1 hour after eating?
Yes
No
Do you suffer from bad breath?
Yes
No
Do you have less than one bowel movement per day?
Yes
No
Do you muscles become easily fatigued?
Yes
No
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Joint Health
Do you suffer from any of the following?
Aches and pains in your joints?
Yes
No
Arthritis?
Yes
No
Stiffness or limitation of movement?
Yes
No
Pain or aches in muscles?
Yes
No
Feeling of weakness or fatigue?
Yes
No
General Health
Do you suffer from any of the following?
Headaches?
Yes
No
Dizziness?
Yes
No
Stuffy Nose?
Yes
No
Chest congestion?
Yes
No
Asthma or Bronchitis?
Yes
No
Shortness of breath?
Yes
No
Difficulty breathing?
Yes
No
Frequent illness?
Yes
No
Frequent or urgent urination?
Yes
No
Acne?
Yes
No
Hives, rashes, dry skin?
Yes
No
Hair loss?
Yes
No
Flushing/hot flushes?
Yes
No
Excessive sweating?
Yes
No
Irregular or skipped heart beat?
Yes
No
Rapid or pounding heartbeat?
Yes
No
Chest pain?
Yes
No
Poor memory?
Yes
No
Mood swings?
Yes
No
Anxiety, fear or nervousness?
Yes
No
Depression?
Yes
No
Binge eating?
Yes
No
Craving certain foods?
Yes
No
Excessive weight gain?
Yes
No
Compulsive eating?
Yes
No
Water retention?
Yes
No
Do you consider yourself underweight?
Yes
No
Fatigue/ sluggish?
Yes
No
Apathy/ lethargy?
Yes
No
Hyperactivity?
Yes
No
Restlessness?
yes
No
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Sleep
Do you have trouble sleeping at night?
Yes
No
Do you have difficulty waking up in the morning?
Yes
No
Do you sleep less than 7-8 hours each night?
Yes
No
Do you wake up once or more in the night?
Yes
No
If you do wake up, what time is it usually at?
Between falling asleep and midnight
Between midnight and 3am
3am and 5am
Multiple times during the night
Do you sleep in a room with lights or noise?
Yes
No
Do you wake up feeling tired?
Yes
No
Do you wake up only to alarms?
Yes
Sometimes
No
Do you go to bed later than 11pm?
Yes
No
Do you struggle to fall asleep?
Yes
Sometimes
No
Do you wake up earlier than 6am?
Yes
No
Do you take medication to help you sleep?
Yes
No
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Rate each of the following symptoms based on your health profile over the last 30 days.
0- never or almost never have these symptoms. 1- Occasionally have it but the effect is not severe. 2- Occasionally have it and the effect is severe. 3- Frequently have it but the effect is not severe. 4- frequently have it and the effect is severe.
Head
Headaches
Faintness
Dizziness
Insomnia
Total score for head
Eyes
Watery or itchy eyes
Swollen, red or sticky eyelids
Bags or dark circles under the eyes
Blurred or tunnel vision
Total score for eyes
Ears
Itchy ears
Earaches or ear infections
Drainage from ear
Ringing in ears or hearing loss
Total for ears
Nose
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total for nose
Mouth and Throat
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discoloured tongue, gums, lips
Canker sores
Total for mouth and throat
Skin
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flushes
Excessive sweating
Total for skin
Heart
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Total for heart
Lungs
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total for Lungs
Digestive tract
Nausea, vomitting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Total for digestive tract
Joints and Muscles
Pain or aches in joints
Arthritis
Stiffness or limitation in movement
Pain or aches in muscles
Feeling or weakness or fatigue
Total for joints and muscles
Weight
Binge eating/drinking
Craving certain foods
Excessive weight gain
Compulsive eating
Water retention
Underweight
Total for weight
Energy and Activity
Fatigue/sluggish
Apathy/lethargy
Hyperactivity
Restlessness
Total for Energy and Activity
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Mind
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total for mind
Emotions
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Total for emotions
Other
Frequent illness
Frequent urination
Genital itch or discharge
Total for other
Grand Total
Add together the total score for each section and write it below
Total
Submit
Should be Empty: