Wellness by Mye Client Success Questionnaire
Complete the questionnaire using the same order, section grouping, and question types as the PDF source.
Personal Information
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Height
*
Current Weight
*
Occupation
Goals
What is your primary goal?
*
What specific results are you hoping to achieve?
*
Why is this goal important to you?
*
Is there an upcoming event or milestone you'd like to feel your best for?
Health History
Do you have any injuries or physical limitations?
Do you have any medical conditions I should know about?
Are you currently taking any medications?
Do you have any food allergies or intolerances?
Fitness Background
How would you describe your fitness level?
*
Please Select
Beginner
Intermediate
Advanced
Other
How many days per week can you realistically work out?
*
How much time can you dedicate to each workout?
*
Will you be working out at a gym, at home, or both?
*
Please Select
Gym
Home
Both
Other
Are there any exercises you cannot perform?
Nutrition & Lifestyle
Walk me through a typical day of eating
*
Approximately how much water do you drink each day?
Foods you enjoy
Foods you avoid
Average hours of sleep per night
Stress level
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Activity level outside the gym
Habits & Accountability
What has stopped you from reaching your goals in the past?
What do you struggle with the most?
Are you willing to track your food if recommended?
*
Please Select
Yes
No
Maybe
How would you like me to hold you accountable?
How committed are you to reaching your goals?
*
Not committed
1
2
3
4
5
6
7
8
9
Fully committed
10
1 is Not committed, 10 is Fully committed
Progress Tracking
Front progress photo
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Side progress photo
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Drag and drop files here
Choose a file
Cancel
of
Back progress photo
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of
Current waist measurement
Current hips measurement
Current chest measurement
Current arm measurement
Current thigh measurement
Agreement & Signature
I acknowledge and agree to the terms and conditions
*
I Agree
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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