Habit Quiz

1

Name

First Name

Last Name

2

EmailBy filling out this form, you agree to be sent emails detailing promotions, sales and fitness advice.

example@example.com

3

Phone Number

Area Code

Phone Number

5

How important are these goals to you?

6

How long have you had these goals for?

Less than 3 months

Between 3 months - 1 year

Between 1-3 years

More than 3 years

7

What has stopped you achieving these goals currently or in the past?

Lack of motivation

Lack of knowledge

Lack of time

Lack of accountability

Injuries

Change in lifestyle

No excuses, just lazy

8

What have you done to over come these challenges?If the answer is nothing you can write that down.

9

Are you progressing on these goals?

YESNO

10

Have you worked with someone to help you?

YESNO

11

Describe your experienceInclude how the experience went, how long you had worked with them and whether you are still working with them.

12

Accountability & Motivation Score

13

How much sleep do you get?Actual sleep time, not hours in bed.

Less than 5 hours

6-7 hours

8 hours

9 or more hours

14

How would you describe your sleep?

Deep, uninterrupted

Broken, wake up more than once a night

15

Why do you wake up during the night?

16

How do you feel when you wake up?

Rested

Groggy

17

Do you go to bed at the same time and wake up at the same time?With in 30 minutes.

Weekdays only

All the time

Never

A few times a week

18

Do you have a sleep routine?

YESNO

19

What is it?

20

How much caffeine do you consume a day?One coffee is 80mg of caffeine. If you have pre workout, find the caffeine content.

None

1-2 coffees

5-6 coffees

3-4 coffees

+7 coffees

21

Sleep Score

22

Do you track your calories?

Yes

No

Most days of the week

Have in the past but not right now

23

How many calories do you have per day on average?

24

If you know, what is your macro split?

26

What is the longest period of time that you have tracked for?

More than 8 weeks

Up to 8 weeks

Up to 4 weeks

Less than 2 weeks

27

Do you snack?

YESNO

28

Why do you snack?

Hunger

Boredom

Temptation

To get more calories in

30

How many meals do you eat out per week?

Once a fortnight

1-2

3-4

+5

31

Do you ever binge?

YESNO

32

How often and why?

33

Do you drink alcohol?

Yes

Only socially

No

35

How much water do you drink a day?

Less than 1 litre

1-2 litres

2-3 litres

More than 3 litres

36

Nutrition Score

38

Do you have any injuries or niggles?

YESNO

39

Describe the nature of the injury.

41

How long have you been training in the gym?

Less than 1 year

Between 1 and 3 years

More than 3 years

42

Do you follow a program?

Yes

No

I have in the past but not currently

44

Do you feel the right muscle working?

All the time

Most of the time

Some times

Not really

I'm not sure what muscle is meant to be working

46

How hard do you train?

I die every session

1-2 reps left in the tank

Some times die, some times okay

Training is pretty easy

47

How sore do you feel the day after training?

Fresh and rejuvenated

A little bit of soreness

Moderately sore, can feel it though out the day

Very sore, life is hard

48

Training Score