Client Questionnaire
Name
First Name
Last Name
Occupation
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which of our services are you interested in?
Mind Body Flow Program
Recovery & Prehab
Strength & Mobility
How did you hear about us?
Referral
Social Media
Online Add
Word of Mouth
Print Ad
Other
What does movement mean to you in your life?
Think deeper than right now. What is something you've always wanted to achieve.
Why did you decide to take the step and start your online assessment today ?
*
What is your biggest fitness goal?
*
Think deeper than right now. What is something you've always wanted to achieve.
If you were able to achieve your goal, would you continue to workout?
*
Of course!
No
Please, I'd love to hear more about your last answer
*
Think deeper than right now. What is something you've always wanted to achieve.
When is your birthdate?
-
Month
-
Day
Year
Date
I would love to get to know your current state of health and your experience with exercise. This will help me determine how I can best help you achieve your movement goal.
Are you currently dealing with any injury or chronic pain?
*
Yes
No
Describe the areas of pain or type of pain that you are feeling (please, skip if you answered no to previous question)
Are you currently seeing any rehabilitative specialist to treat this pain? (please, skip if you do not experience pain)
Rehab Specialist include Physical Therapist, Chiropractor, Massage Therapist
Back
Next
Now, I would love to get to know your current state
Please, describe your current movement regimen
*
If you haven't been physically active, how long has it been since you were and please tell me what a regular day looks like to you (daily routine)
Do you have any previous cardiac issues?
*
Yes
No
Do you have a specific timeline for these goals?
*
1 month - 2 months
3 months - 6 months
6 months to long term changes
Back
Next
We spend 30% to 50% of our day at our jobs. Understanding that environment is critical to helping you achieve your goal
These next questions will dive into that area of your life.
What best describes your day to day activities at work?
*
Sedentary (sitting mostly)
Active (I'm on my feet most of the day)
Random (i find myself in-between active and sedentary)
How flexible is your schedule and where can you find yourself fitting your health and fitness into your routine.
*
9-5 (catch me before or after work)
Salary/WFH (I'll block it in my calendar)
Flexible (I control my schedule)
Back
Next
Finally, eliminating time, money, and pain from the equation; What has been the biggest obstacle in you achieving your movement goal?
*
Thank you so much for your time. I will go through your questions and contact you within the next seven days to schedule a zoom call and talk about how we are going to get started on helping you achieve your brand new lifestyle through movement
Submit
Should be Empty: