Client questionnaire

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
FemaleMale
Height
cm
Weight
kg
Phone Number
Please enter a valid phone number.Format: (00000000000) .
Email
example@example.com
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Do you have any injuries? If yes, please list below.
YesNo
Not at allOnce a monthOnce a weekMore than once a week
Why is doing this important to you?
Explain your current diet below
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Should be Empty:

Your Information