NEW CLIENT QUESTIONNAIRE
Part I: General Information
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
How did you hear about us?
Part II: Nutrition Information
On a scale of 1-10, how would you rate your Nutrition (1=poor 10=excellent)?
Why did you score yourself that and what could make you a 10?
How many times a day do you usually eat (including snacks)?
Do you skip meals?
Do you eat breakfast?
Describe your typical Breakfast
Do you eat late at night?
What activities do you engage in while eating?
How many glasses of water do you consume daily?
How many times per week do you eat out?
Do you know how many calories you eat per day?
Do you do your own cooking?
Do you eat foods high in fat?
Do you eat foods high in sugar?
Please list any vitamins or any other food supplements you are taking.
Besides hunger, what other reason(s) do you eat?
Do you eat past the point of fullness?
List 3 areas of your Nutrition you would like to improve:
List everything you ate yesterday and roughly at what time: including oil for cooking, mayo on sandwiches ect.
Part III: Medical History
Any questions you answer yes to please fill out details at the bottom of this page regarding that answer.
Do you have any injuries, illnesses, and/or conditions that may inhibit or limit exercise? (Ex. lower back problems, knee problems, arthritis, vertigo, pregnancy)
Do you suffer from back pain, sore knees or shoulder pain?
Do you have any lung problems? (E.g. asthma, bronchitis)
Do you have tension, numbness or pain in specific area?
Are you pregnant?
Do you have high blood pressure?
Do you have low blood pressure?
Do you have high cholesterol?
Have you ever had surgery?
Have you ever broken any bones?
Do you experience stiff, swollen or painful joints?
Do you have difficulty sleeping?
Do you experience fatigue or lack of energy?
Have you ever been advised by a physician to avoid any type of exercise?
Do you (or does someone in your family) have a cardiac condition?
Are you currently taking any medications?
Do you smoke or have you smoked in the past?
Do you drink alcohol?
Were you overweight as a child?
Were you overweight as a child?
Is anyone in your family overweight?
Describe in Detail your YES answers here.
Continued area to respond to yes answers.
Please describe any other known issues that may be affected by physical exercise.
Part IV: Exercise History
How many times a week can you realistically commit to your workout?
On what days of the week?
How much time do you realistically want to invest per training session?
Are you currently going to a gym, attending classes, or sports?
If yes please list here.
In the past 3 months please describe in detail any exercise history you have done. Including type and number of workouts if any.
Describe the past 6 months of any physical activity.
Do you start exercise programs but then find yourself unable to stick with them?
If your participation is lower than you would like it to be, what are the reasons?Ie. Lack of interest, cost, lack of facility, time, injury, lack of knowledge, ect.
How long has it been since you were last on a structured exercise routine?
Rate yourself on a scale of 1 to 10 (1 indicating the lowest value and 10 indicating the highest). Your present overall fitness ability.
Rate yourself on a scale of 1 to 10 (1 indicating the lowest value and 10 indicating the highest). Your present overall flexibility ability.
Rate yourself on a scale of 1 to 10 (1 indicating the lowest value and 10 indicating the highest). Your present overall cardiovascular capacity.
Rate yourself on a scale of 1 to 10 (1 indicating the lowest value and 10 indicating the highest). Your present overall strength.
What are you likes/dislikes about exercising?
Do you have Diastasis Recti (abdominal separation)?
Do you have a weak pelvic floor (urinary incontinence) or tight pelvic floor (pain from intercourse or pubic pain, difficulty peeing)?
If you answered yes please describe your issue(s).
Part V: Exercise Goals
What are your fitness goal(s) you’d like to work towards?
Why are these your goals? Be specific.
Please list specific body areas you want to work on and how you want them to look.
Please check all items that are important to you
Improve cardiovascular fitness
Body-fat weight loss
Reshape or tone my body
Functional Training-Improve activities of Daily Living
Improve moods and ability to cope with stress
Improve flexibility, posture & balance
What are your top 3 listed in order of importance
Do you own any fitness equipment?
If yes please list all items here including the weight.
Ie. 1 set 5lb dumbbells, 1 20lb kettlebell.
What cardio activities interest you?
How committed are you to achieving your fitness goals?
Outline what you feel are the obstacles or your potential actions, behaviours or activities that could impede your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise etc.).
Outline 3 methods that you plan to use to overcome these obstacles:
Part VI: Health Journey Emotions
Limiting Beliefs Recognized
Do you feel like you are always on a diet?
Do you wonder what is wrong with you?
Do you hate looking in the mirror?
Do you have a hard time finding clothes that fit?
Do you hear yourself say I eat my emotions?
Have you lost weight but gained it back or more?
Do you think losing weight is hard?
Do you think food has control over you?
Do you have a hard time fitting exercise into your scheduleand when you do it’s a burden and you hate it?
Part VII: Other Information
I want to hear your story.
Why did you choose to work with me and take this next step?
Have you tried something like this before? Tell me about your experience.
What are your biggest struggles in life, work, relationships & health?
What are you hoping to achieve from this process?
Good work! You're finished! Just press the submit button below.
You'll hear back from us shortly.
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm