THRIVING LIVES HEALTH & LIFESTYLE QUESTIONNAIRE
Thank you for your interest in working with Thriving Lives! This questionnaire is very in depth but essential in helping us address any underlying health issues and ultimately helping you reach both your short and long term goals. Please be thorough in your completion of this questionnaire.
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Address (I like to surprise my clients sometimes with gifts, giveaways, etc.)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Thriving Lives Fitness? If you were referred by somebody please tell me who!
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After hearing about Thriving Lives, how long did you wait before reaching out?
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Days
1-2 Months
3-6 Months
6-12 Months
Year +
Age
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Weight
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Height
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Biological Gender
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What do you do for a living? Is it a job that you enjoy? Is it stressful?
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Tell me about your family. Significant other, kids, etc? If you have a significant other, are they interested in joining with you? If not, are they supportive?
Active or former military?
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Why are you here? (select all that are true)
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I want to improve my body composition
I want to improve my energy
I want to improve my confidence
I want to be a role model for my children (others)
I have failed so many "diets" before
I want to learn healthy nutrition habits
I have no idea what I am doing and need guidance
I want to build a sustainable-healthy-balanced lifestyle
I have a big event coming up
Enough is ENOUGH
I struggle to hold myself accountable and need your help with this
I want to form a better fitness routine
Other
Anything you would like to add about your WHY?
MINDSET
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Disagree
Sometimes Agree
Agree
Strongly Agree
I believe in myself
I am resilient
I am adaptable
I can be flexible
I am reflective
I run from a challenge
I see mistakes as failure
I see mistakes as an opportunity to learn and grow
I have a hard time holding myself accountable
I handle stress well
I live a very fast paced, go-go-go lifestyle
I prioritize my health
I am an "All or Nothing" person
I am balanced
My self-talk is very critical (I am very hard on myself)
I look for excuses
I look for solutions
I am confident
Workout Experience
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None or Minimal - I need help with the basics.
Experienced - I know my way around the gym, I understand proper form but I don't feel confident in more complex movements such as a barbell squat or deadlift.
Advanced - I have years of experience in the gym and am confident in my ability to perform more complex movements and training programs.
Describe your current exercise routine (if any) - Frequency, Intensity, Type, Duration
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How many steps do you get on an average day? If you don't have any idea then tell me how many hours a day do you spend on your feet.
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Where will you be working out at? Home or Gym? If home, please tell me what equipment you have access to. If at a gym, what gym?
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Please describe a normal day of eating. Include meal times, average meal, and if you track calories/macros/etc please tell me those as well.
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Do you feel confident in tracking macros? If you have no idea what I'm talking about NO WORRIES, just tell me you don't know (:
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How many mg of caffeine do you have on a daily basis? List how many cups of coffee, energy, drinks, teas, soda (diet or full sugar) that you have on an average day.
How many alcoholic beverages do you have in an average week? What types of drinks do you have when you drink alcohol? When drinking, how often is it for stress relief after a long day/week?
What is your preferred type of diet?
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No Preference
Balanced
Vegan
Vegetarian
Other
PROTEIN - What sources of PROTEIN do you like? (select all that apply)
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Chicken
Ground Beef
Ground Turkey
Steak
Fish
Eggs/Egg Whites
Protein Powder
CARBOHYDRATES - What sources of CARBS do you like? (select all that apply)
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Rice
Potatoes
Sweet Potatoes
Quinoa
Pasta
Bread
Sweets
Vegetables
Fruits
Cereal
Pancakes/Waffles
Oatmeal
Beans/Lentils
FATS - What sources of FAT do you like? (select all that apply)
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Avocado
Olive Oil
Coconut Oil
GHEE Butter
Grass Fed Butter
Almond Butter
Nuts
Cheese
List any specific foods you would like me to try to include on your plan if at all possible.
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List any foods you are ALLERGIC to, know you're sensitive to, or that you just hate and won't eat.
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For the next several sections you will rate each health symptom based on your typical health profile for the previous month.
Point Scale: 0 - Never or almost never have the symptom 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe
DIGESTIVE TRACT
*
0
Never or almost never have the symptom
1
Occasionally have it, effect is not severe
2
Occasionally have it, effect is severe
3
Frequently have it, effect is not severe
4
Frequently have it, effect is severe
NAUSEA, VOMITTING
DIARRHEA
CONSTIPATION
BLOATED FEELING
BELCHING, PASSING GAS
HEARTBURN
INTESTINAL, STOMACH PAIN
JOINTS & MUSCLE
*
0
Never or almost never have the symptom
1
Occasionally have it, effect is not severe
2
Occasionally have it, effect is severe
3
Frequently have it, effect is not severe
4
Frequently have it, effect is severe
PAIN OR ACHES IN JOINTS
ARTHRITIS
STIFFNESS OR LIMITATION OF MOVEMENT
FEELING OF WEAKNESS OR TIREDNESS
PAIN OR ACHES IN MUSCLES
Describe Any and All Past/Current Injuries & Elaborate on Any Muscle/Joint Question that you answered 2+ on
Weight
*
0
Never or almost never have the symptom
1
Occasionally have it, effect is not severe
2
Occasionally have it, effect is severe
3
Frequently have it, effect is not severe
4
Frequently have it, effect is severe
BINGE EATING/DRINKING
CRAVING CERTAIN FOODS (SALT OR SWEET)
EXCESSIVE WEIGHT
WATER RETENTION
UNDERWEIGHT
COMPULSIVE EATING
ENERGY & ACTIVITY
*
0
Never or almost never have the symptom
1
Occasionally have it, effect is not severe
2
Occasionally have it, effect is severe
3
Frequently have it, effect is not severe
4
Frequently have it, effect is severe
FATIGUE/ SLUGGISHNESS
APATHY, LETHARGY
HYPERACTIVITY
RESTLESSNESS
NO EXCERCISE
EXCESSIVE EXERCISE (DAILY INTENSE)
EMOTIONS
*
0
Never or almost never have the symptom
1
Occasionally have it, effect is not severe
2
Occasionally have it, effect is severe
3
Frequently have it, effect is not severe
4
Frequently have it, effect is severe
MOOD SWINGS
ANXIETY, FEAR, NERVOUSNESS
ANGER, IRRITABILITY, AGGRESSIVENESS
DEPRESSION
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The following page serves as our agreed upon: Contract, Agreement of Price and Payments, Cancellation Policy, No Refund Policy, Non-Disclosure Agreement, Non-Compete Agreement, Assumption of Risk-Disclaimer. Thriving Lives Fitness understands that we may not have spoken about your program options, pricing, or anything else YET. This is ONLY binding IF you decide to sign up and purchase a program with Thriving Lives Fitness. If you choose to not purchase a program/membership then you will not be held to this contract. Please carefully read the following:
Disclaimer: The following information is a complete overview of the Thriving Lives Fitness Contract. ---- No Refund Policy: All sales, fees, and purchases are final and non-refundable. I understand and acknowledge that no refundof any kind will be given under any circumstances.Agreement of Price and Automatic Payment via Trainerize. The payment and/or price will be mutually agreed upon together during or following our consultation call. Monthly payments require a MINIMUM of 6 monthly payments. If you purchase a Paid in Full plan, disregard the minimum of 6 monthly payments statement. Trainerize will automatically charge on the day of the month that the program was originally purchased. If payment fails, Trainerize will attempt to re-run the payment two additional times before automatically deactivating the account. In the event of deactivation or non-payment for any reason, the required minimum of 6 payments will still be due to Thriving Lives Fitness LLC. If failure to make these payments continues, Thriving Lives Fitness LLC will be forced to send the issue to collections. I understand and acknowledge that I will be responsible for the minimum of 6 monthly payments made in a timely manner each month. ---- Cancellation Policy Full payment of membership or completion of a minimum of 6 monthly payments is required for cancelation regardless of the reason. Cancelation will only be approved after an exit phone call with Marcus Gates or Renae Hill. You must initiate cancellation in writing to Marcus Gates or Renae Hill no later than two business days before your next scheduled payment. If cancelation is initiated after this time period your next payment will still be processed and your cancelation will go into effect before the then following payment is made. ---- Non-Disclosure Agreement: This agreement falls under the Kansas Uniform Trade Secrets Act. I understand and acknowledge I will not directly or indirectly disclose, publish, communicate, or make available any diet plans, workout routines, documents, and/or confidential information obtained through Thriving Lives Fitness LLC. I understand and acknowledge that Thriving Lives Fitness LLC has expended and continues to expend significant time and expense in creating this program for the benefit of their clients. Failure to adhere to this would cause significant and irreparable harm and will result in immediate termination of the program. No refund will be given under these circumstances. ---- Non-Compete Agreement: I understand and acknowledge I am not to engage in a similar field of business with a client or potential client ofThriving Lives Fitness LLC. I will not directly or indirectly solicit or attempt to solicit the business or patronage of any person, corporation, or entity in competition with Thriving Lives Fitness LLC nor service contracts or accounts involving for any person, corporation, or other entity other than Thriving Lives Fitness LLC. I agree that this covenant not to compete is reasonably necessary to protect the Thriving Lives Fitness’ legitimate interests and does not impose an undue hardship. ---- Assumption of Risk: By signing below, I hereby expressly and affirmatively state that I wish to participate in the Thriving Lives Fitness Nutrition and/or Fitness Plan." This program is designed as an online program meaning we will not be working together in person. I understand and acknowledge it will be my responsibility to accurately understand each exercise and execute them correctly when performing each and every movement. If I do not understand an exercise, it is my responsibility to ask Thriving Lives Fitness LLC and/or my trainer to advise how to correctly perform it. Thriving Lives Fitness will not be held liable for any injuries that occur from the improper application of an exercise. ---- Marcus Gates and Renae Hill are not medical doctors or registered dietitians. The contents of this program or conversations with Marcus Gates or Renae Hill should not be taken as medical advice. It is not intended to diagnose, treat, cure, or prevent any health problem - nor is it intended to replace the advice of a physician. Always consult your physician or qualified health professional on any matters regarding your health. Before signing up for any health/and or fitness programs always consult a physician. Those with prior health issues or heart conditions should take extra precaution. Not properly consulting with a physician and performing exercises incorrectly can lead toserious injuries, and in extreme cases, death. I have had an opportunity to ask questions. ---- Any questions which I have asked have been answered to my complete satisfaction. I subjectively understand the risk of my participation in this activity, and knowing and appreciating these risks I voluntarily choose to participate, assuming all risk. ---- This agreement is and will be held to it's accuracy in all 50 states of The United States of America.
This is a Legally Binding Agreement and is required to join Thriving Lives Fitness.
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