FitKicks Detailed Questionnaire

1
Image Field
2
Name
First Name
Last Name
3
Do you smoke?
YESNO
4
How much do you smoke?Enter as much detail as possible
5
Do you drink alcohol?
YESNO
6
How many glasses a week?
7
How many hours do you normally sleep a night?
8
Describe Your Job
Sedentary
Active
Physically Demanding
9
Does your job require travel?
YESNO
10
How would you rate your stress level?
Service Quality
Overall Hygiene
Responsiveness
Kindness and Helpfulness
Very Low
Low
Average
High
Very High
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Very Low
Low
Average
High
Very High
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Very Low
Low
Average
High
Very High
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Very Low
Low
Average
High
Very High
Row 3, Column 0Row 3, Column 1Row 3, Column 2Row 3, Column 3Row 3, Column 4
Service Quality
Overall Hygiene
Responsiveness
Kindness and Helpfulness
Very Low
Low
Average
High
Very High
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Very Low
Low
Average
High
Very High
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4
Very Low
Low
Average
High
Very High
Row 2, Column 0Row 2, Column 1Row 2, Column 2Row 2, Column 3Row 2, Column 4
Very Low
Low
Average
High
Very High
Row 3, Column 0Row 3, Column 1Row 3, Column 2Row 3, Column 3Row 3, Column 4
11
List your 3 biggest sources of stress:
12
Is anyone in your family overweight?
Mother
Father
Sibling
Grandparent
13
Were you overweight as a child?
YESNO
14
When were you in the best shape of your life?
15
Have you been exercising consistently for the past 6 months?
YESNO
16
When did you first start thinking about getting in shape?
17
What if anything stopped you in the past?
Huge
Large
Normal
Small
Ok
Ok
18
How would you rate your present fitness level?
Fitness Level
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
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Fitness Level
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
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19
How often do you take part in physical exercise?
1-2x/week
3-4x/week
5-7x/week
20
If your participation is lower than you would like it to be, what are the reasons?
21
How long have you been consistently physically active for?
22
Describe your exercise routines for the last 6 monthsBe specific. The more information, the better we can design an appropriate program for you
Huge
Large
Normal
Small
Ok
Ok
23
How would you rate your Nutrition?
1
2
3
4
5
Poor
Excellent
24
How many times a day do you usually eat (including snacks)?
25
Do you skip meals?
YESNO
26
Do you eat breakfast?
YESNO
27
Do you eat late at night?
Sometimes
Often
Never
28
How many glasses of water do you consume daily?
29
Do you feel drops in your energy levels throughout the day?
YESNO
30
What time of day do you feel drops in energy?
31
Have you measured your daily calorie intake in the last 3 months?
YESNO
32
How many calories are you consuming, on a typical day?
33
Are you currently or have you ever taken a multivitamin or any other food supplements?
YESNO
34
Please list the supplements:
Huge
Large
Normal
Small
Ok
Ok
35
At work or school, do you usually:
Eat out
Bring your own food
36
How many times per week do you eat out?
37
Do you do your own grocery shopping?
YESNO
38
Do you do your own cooking?
YESNO
39
Besides hunger, what other reason(s) do you eat?
Boredom
Social
Stressed
Tired
Depressed
Happy
Nervous
40
Do you eat past the point of fullness?
Often
Sometimes
Never
41
Do you eat foods packaged foods, processed foods, sweets, desserts, fried food?
Often
Sometimes
Never
42
List 3 areas of your Nutrition you would like to improve:
43
List any known allergies
Huge
Large
Normal
Small
Ok
Ok
44
List your 5 favourite foods
Huge
Large
Normal
Small
Ok
Ok
45
List your 5 least favourite foods
46
How can a Personal Trainer help you? Please check that which applies.
Lose Body Fat
Develop Muscle Tone
Rehabilitate an Injury
Nutrition Education
Start an Exercise Program
Design a more advanced program
Safety
Sports Specific Training
Increase Muscle Size
Motivation
Other
47
Please list in order of priority, the fitness goals you would like to achieve in the next 3-12 months?
48
How will you feel once you’ve achieved these goals?Be Specific
Huge
Large
Normal
Small
Ok
Ok
49
Where do you rate health in your life?
Low Priority
Medium Priority
High Priority
50
How committed are you to achieving your fitness goals?
Very
Semi
Not Very
51
What do you think the most important thing your Personal Trainer can do to help you achieve your fitness goals?
Huge
Large
Normal
Small
Ok
Ok
52
Outline what you feel are the obstacles or your potential actions, behaviors or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise etc.).
Huge
Large
Normal
Small
Ok
Ok
53
Outline 3 methods that you plan to use to overcome these obstacles:
54
How did you hear about us? Please check that which applies.
Google
Social Media
Referral
Website
Other
55
Who referred you to us? We would love to express our gratitude to them
56
Why did you choose to train with us instead of another organization? Please check that which applies.
Location
Personal Trainers
Cost
Service
Word of Mouth
Programs
Other
57
What would cause you to discontinue training with us ?
Huge
Large
Normal
Small
Ok
Ok
58
The Gift of Fitness - At FitKicks we rely on happy clients telling others about our services. We may both be able to make a huge difference in somebody's life. Please take the time to jot down the names of 2 friends who you would like to offer a complimentary consultation to. Once you discuss this with them, we'll call them and book them for their first session
1. Name
Phone Number
2. Name
Phone Number
59
SignatureI believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.
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