NEW CLIENT QUESTIONNAIRE
Part I: General Information
Name
First Name
Last Name
Address
Street Address
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
E-mail
Birthday
Mos/ Day/Year
How did you hear about us?
Emergency Contact
First Name
Last Name
Relationship
Phone Number
-
Area Code
Phone Number
Current Weight
Height
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?
Yes
No
Do you eat breakfast?
Yes
No
Describe your typical Breakfast
Do you eat late at night?
Yes
No
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?
Yes
No
Do you do your own cooking?
Yes
No
Do you eat foods high in fat?
Yes
No
Do you eat foods high in sugar?
Yes
No
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?
Sometimes
Never
Often
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)
Yes
No
Do you suffer from back pain, sore knees or shoulder pain?
Yes
No
Do you have any lung problems? (E.g. asthma, bronchitis)
Yes
No
Do you have tension, numbness or pain in specific area?
Yes
No
Are you pregnant?
Yes
No
Do you have high blood pressure?
Yes
No
Do you have low blood pressure?
Yes
No
Do you have high cholesterol?
Yes
No
Have you ever had surgery?
Yes
No
Have you ever broken any bones?
Yes
No
Do you experience stiff, swollen or painful joints?
Yes
No
Do you have difficulty sleeping?
Yes
No
Do you experience fatigue or lack of energy?
Yes
No
Have you ever been advised by a physician to avoid any type of exercise?
Yes
No
Do you (or does someone in your family) have a cardiac condition?
Yes
No
Are you currently taking any medications?
Yes
No
Do you smoke or have you smoked in the past?
Yes
No
Do you drink alcohol?
Yes
No
Were you overweight as a child?
Yes
No
Were you overweight as a child?
Yes
No
Is anyone in your family overweight?
Yes
No
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?
Yes
No
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?
Yes
No
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)?
Yes
No
Dont Know
Do you have a weak pelvic floor (urinary incontinence) or tight pelvic floor (pain from intercourse or pubic pain, difficulty peeing)?
Yes
No
Dont Know
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
Increase strength
Increase energy
Increase Size
Other
What are your top 3 listed in order of importance
Do you own any fitness equipment?
Yes
No
If yes please list all items here including the weight.
Ie. 1 set 5lb dumbbells, 1 20lb kettlebell.
What cardio activities interest you?
Running/Jogging
Swimming
Rower
Stairs
Spin
Elliptical
Low Impact
High Impact
Not Sure
Other
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?
Why?
Do you wonder what is wrong with you?
Why?
Do you hate looking in the mirror?
Why?
Do you have a hard time finding clothes that fit?
Why?
Do you hear yourself say I eat my emotions?
Why?
Have you lost weight but gained it back or more?
Why?
Do you think losing weight is hard?
Why?
Do you think food has control over you?
Why?
Do you have a hard time fitting exercise into your scheduleand when you do it’s a burden and you hate it?
Why?
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?
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