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
*
Please enter a valid phone number.
Format: (000) 000-0000.
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?
*
Days
1-2 Months
3-6 Months
6-12 Months
Year +
Age
*
Weight
*
Height
*
Biological Gender
*
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
*
Rows
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
*
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.
*
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?
*
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.
*
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 (:
*
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?
How many ounces of water do you drink on a normal day?
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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)
*
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)
*
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.
*
List any foods you are ALLERGIC to, know you're sensitive to, or that you just hate and won't eat.
*
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
*
Rows
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
*
Rows
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
*
Rows
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
*
Rows
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
*
Rows
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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