Success Questionnaire
Let's go!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Height (inches)
*
Current Body Weight (pounds)
*
How did you hear about the SBSC coaching program?
*
Have you ever worked with a strength and conditioning coach before?
*
Please Select
Yes
No
If yes, what were the results?
Can you briefly described your specific, short-term goals (over the next 12-weeks)?
*
Can you briefly describe your specific, long-term goals (over the next year)?
*
How much time are you willing to dedicate to reaching your goals?
*
Why is this goal important to you?
*
How important is it that you reach your goals?
*
Please Select
Not Important
Somewhat Important
Important
Very Important
Do you have any specific injuries you're dealing with?
*
Please Select
Yes
No
If yes, please provide details.
Are you consistently training now?
*
Please Select
Yes
No
How would you rate your current level of fitness or performance capability?
*
Please Select
Poor
Fair
Average
Excellent
Is there anything else you would like us to know?
*
Back
Next
Physical Readiness Questions
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
*
Please Select
Yes
No
Do you feel pain in your chest when you perform physical activity?
*
Please Select
Yes
No
In the past month, have you had chest pain when you were not performing any physical activity?
*
Please Select
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Please Select
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*
Please Select
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
*
Please Select
Yes
No
Do you know of any other reason why you should not engage in physical activity?
*
Please Select
Yes
No
Back
Next
Nutrition Questions
How do you rate health in your life?
*
Not Important
1
2
3
4
Extremely Important
5
1 is Not Important, 5 is Extremely Important
How healthy do you usually eat?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How many times do you eat throughout the day?
*
Do you skip meals throughout the day?
*
Please Select
Yes
No
Do you eat breakfast?
*
Please Select
Yes
No
What kinds of food do you regularly eat?
*
How many ounces of water do you consume daily?
*
Do you feel hydrated throughout the day?
*
Please Select
Yes
No
How many grams of protein are you consuming on a daily basis?
*
How many alcoholic drinks are you consuming per day?
*
When are you most tired?
Please Select
Early Morning
Late Morning
Early Afternoon
Late Afternoon
Evening
When do you have the most energy?
Please Select
Early Morning
Late Morning
Early Afternoon
Late Afternoon
Evening
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform