Fitness Coaching Consultation Questionnaire
Demographics
Name
*
First Name
Last Name
Age
*
years
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Height (ft / in)
*
Body Weight (lbs)
*
Fitness Goals
Please rank the following goals in order of their importance relative to each other, with 1 being most important and 7 being least important. For example, if your top priority is fat loss, assign that "1"; if improving your strength is your 4th priority, assign that "4" and so on.
*
1
2
3
4
5
6
7
Improved Health
Improved Endurance
Improved Strength
Improved Muscle Mass
Fat Loss
Weight Gain
Sports Specific
Please describe your specific goals (eg. amount or % body fat loss, amount of lean muscle, specific body appearance, specific sports needs etc).
*
If you have any, what are your specific time frames for achieving your goal(s) (be as detailed as possible).
*
Please select which type of progress is more important for you
*
Immediate progress which is less easily maintained
Maintainable progress which may be less rapid
Training Experience
What is your level of fitness / strength training experience?
*
Beginner (1 year)
Intermediate B (>1 year in past 5 years, but not currently training)
Advanced (currently >2 years consistently training)
Do you currently train at least 3 times per week?
*
Yes
No
IF you ARE training >3x per week, please describe your training in a typical week (enter RT for resistance/weight training, LISS for low-intensity cardio, HIIT for high-intensity interval training, SS for sports or sports-specific training)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Type (use key above)
Duration (min)
IF you ARE NOT training >3x per week, have you ever been on a consistent exercise program of >3x/wk?
Yes
No
If yes to the above, how long ago was this, and for how long did you participate in this training program>
Please describe what you have previously tried regarding exercise/activity, nutrition, lifestyle (or other efforts) to achieve these goals.
*
Have you previously worked with a fitness coach? If yes, how long ago and for what duration? Please describe your expectations of your fitness coach
*
Commitment
Are you willing to exercise for at least 5 hours per week?
*
Yes
No
Do you currently have routine access to a gym?
*
Yes
No
Are you willing to spend at least 30 minutes per day preparing your meals?
*
Yes
No
Make a selection on the scale of 1-10 to describe how committed you are to the level of consistency which will be required to achieve your fitness goals?
*
1
2
3
4
5
6
7
8
9
10
10 being absolutely committed, and 1 being poorly committed
What do you expect will be your main challenges?
*
How will you plan for an overcome the challenges you anticipate?
*
Medical
This is not a substitute for a Physical Activity Readiness Questionnaire (PAR-Q), which will need to be completed prior to any training.
If you have any diagnosed health conditions, please list/describe your condition(s)
*
If you are currently on any medications, please list them.
*
Please list any current or previous injuries (include timing)
*
Please list any prior surgeries and timing
*
Do you suffer from any of the following?
*
Yes
No
Joint aches and pains
Arthritis
Stiffness or limitation of movement
Muscular aches or pains
Feelings of weakness or tiredness
Anxiety fear or nervousness
Depression
Binge eating
Craving certain foods
Excessive weight gain
Compulsive eating
Apathy or lethargy
Hyperactivity or restlessness
Anger, irritability, or aggressiveness
Do you smoke?
*
Yes
No
If yes, how many cigarettes on average per day?
*
Do you drink alcohol?
*
Yes
No
If yes, how many units per week (175 ml of wine=2 units, 1 pint of beer=3 units)
2-5
5-10
>10
Career & Lifestyle
What do you do for a living?
*
What level of physical activity is required for your job?
*
None
Moderate
High
Does your job involve shift work?
*
Yes
No
If your job involved a regular schedule, do you work mornings, days or nights?
*
mornings
days
nights
How often do you travel?
*
Rarely
1-3 times per year
1-2 times per month
Weekly
Do you have children?
*
Yes
No
Do you participate in other physical activities outside of work and the gym? if yes, please describe.
*
How many times per week do you go food shopping?
*
Once
Twice
>3 Times
How many times per week do you eat out at restaurants or order delivery/takeaway meals?
*
Never
Once
1-2 Times
3-5 Times
>5 Times
Please make a selection to describe your average daily stress level.
*
Very low
Low
Moderate
High
Very High
What stress management approaches do you regularly use? How effective is each?
Sleep
Please respond yes or no to the following
*
Yes
No
N/A
1-3am
3-5 am
Do you have trouble falling asleep at night?
Do you have difficulty waking up in the morning?
Do you sleep less than 7-8 hours each night?
Do you wake up more than once per night?
If you do wake up, what time is it?
Do you sleep in a room with any light or noise?
Do you wake up feeling tired?
Do you wake up only with an alarm?
Do you go to bed on average later than 11 pm?
Do you get up earlier than 6 am?
Do you use medication to help you sleep?
Nutrition & Digestion
Please describe your current nutritional habits. Include (1) food types and quality (2) If known, the approximate number of calories, grams of protein, carbs and fats per day
*
How much fluid do you take in on an average day?
< 1.5 liters (50 fl oz)
2.0 liters (67 fl oz)
2.5 liters (85 fl oz)
3.0 liters (100 fl oz)
3.5 liters (120 fl oz)
>3.5 liters (>120 fl oz)
What aspect of your nutrition, if any would you like to improve?
*
Have you ever tracked your calories or followed a specific nutritional plan? Please describe. Include positive and negative experiences, as well as any challenges faced and how you approached and overcame them
*
Do you suffer from any of the following?
*
Yes
No
Indigestion or Heartburn
Gas
Constipation
Diarrhea
Do you have a sense of fullness after meals
Bloating 1 hr after eating
Bad breath
Other
General & Joint Health
Do you suffer from any of the following
Yes
No
N/A
Headaches
Dizzziness
Nasal congestion
Chest congestion
Asthma or bronchitis
Shortness of breath or difficulty breathing
Frequent illness
Frequent or urgent urination
Hair loss
Hot flashes
Excessive sweating
Irregular or skipped heart beats
Rapid heart beat
Chest pain
Water retention
Food Diary
Please complete the food diary below. This is an important aspect of our consultation, and at least 1 day is required prior to attending the consultation. In the "Food" Column please add general descriptive information (eg eggs, toast, rice, chicken breast). For "Energy Level" columns, please use "L", "N", "H" to indicate low, normal, or high. For the "Portion Size" column - please use "S", "M", "L" to indicate small, medium, or large.
DAY 1
*
Food
Time
Portion Size
Energy Level Before
Energy Level After
Meal / Snack 1
Meal / Snack 2
Meal / Snack 3
Meal / Snack 4
Meal / Snack 5
Meal / Snack 6
Meal / Snack 7
Please add any additional information or context to the nutritional log above
DAY 2
Food
Time
Portion Size
Energy Level Before
Energy Level After
Meal / Snack 1
Meal / Snack 2
Meal / Snack 3
Meal / Snack 4
Meal / Snack 5
Meal / Snack 6
Meal / Snack 7
Please add any additional information or context to the nutritional log above
Signature
*
Submit
Should be Empty: