Fill Questionnaire please
1-First Name
2- Last Name
3- Gender
4-Age
5- Phone Number. Please include your area code
6- Email
7- Confirm Email
8- What is your current weight?
9- What is your height?
10- What are your fitness and nutrition goals? For example, are they to have a flat tummy, toned body, lose weight, gain weight, bigger buttocks, etc. Be as descriptive as possible.
11- What is keeping you from achieving your Fitness & Nutrition goals? (Check all that apply)
Lack of Motivation
Not enough Equipment
Not enough of Time
Lack of Results
Hitting a Plateau
Self Conscious
Not Knowing Where or How to Start
Other
12- What motivates you? (Check all that apply)
Seeing Results
Having Fun
Praise/Rewards
Feeling Better
Other
13- Do you follow a current exercise regime? If yes, please explain.
No
Yes
14- Are there any physical aspect that limit your participation in exercise? If yes, please explain.
No
Yes
15- Are you currently employed? If so, what type of physical activity do you do at work? Heavy lifting sitting, etc..
No
Yes
16- What activities/exercises do you currently participate in? (Check all that apply)
Running/Walking, Aerobics, Strength Training, Circuit Training, Biking
Dance
Free Weights
Swimming
Yoga/Pilates
Martial Arts
Sports
None
Others
17- Tobacco Use:
I currently smoke
I quit smoking < 6 months ago
I quit smoking over 6 months ago
I never used tobacco
18- Alcohol Use:
I frequently drink alcohol
I occasionally drink alcohol
I seldom drink alcohol
I never drink alcohol
19- What is your current activity level?
None
Little (Less than one hour a week)
Moderate (1-5 hours a week)
High (Over 5 hrs. a week)
20- Do you have any food allergies? If yes, please explain
No
Not that I know
Yes
21- How often do you eat out?
Almost Every day
Once a Week
Once a Month
A Few Times a Week
A Few Times a Month
Rarely or Never
22- Prepare a three day food journal. Basically let us know everything you ate the past three days.
23- On average how much sleep do you usually get every night?
4 hours or less
5 to 6 hours
7 to 9 hours
More than 9 hours
24- How would you describe your current diet? (Vegetarian, Vegan, Paleo etc...)
25 - How much time do you spend sitting or being sedentary during the day?
1 to 6 hours
7 to 12 hours
13 to 18 hours
19 to 24 hours
26- Do you have any exercise preferences or specific activities you enjoy?
27- How would you describe your health?
Poor
Fair
Good
Excellent
28- Are you taking any prescription or over-the-counter medications or dietary herbs or any vitamins, minerals, or supplements? Yes/No
29- Do you have or has your doctor or another licensed healthcare professional told you that you have any of the following conditions?
Allergies
Amenorrhea or absence of menstrual period >3 months
Anemia
Anxiety
Arthritis
Asthma
Cancer
Cardiovascular disease
Celiac disease
Chronic sinus condition
Cigarette smoker
Crohn’s disease
Depression
Diabetes
Disordered eating
Intestinal problems
Gastroesophageal reflux disease (GERD)
High blood pressure/ hypertension
Hyper/hypo-thyroidism
Hypoglycemia
Insomnia
Intestinal problems
Irritable bowel syndrome
Osteoporosis
Polycystic ovary disease
Currently pregnant or < 3 months postpartum
Past injuries
Surgeries or hospitalization
30- Describe any other health conditions you have, or for which you take medication?
31- What would you like to do regarding your weight?
Lose
Maintain
Gain
32- Is there any other information that you think I should know? If yes, please explain.
No
Yes
33- Are there any foods that cause you digestive issues? If yes, please explain.
No
Yes
34- What foods you will not or would prefer not to eat?
SUBMIT
Please Double Check All The Information You Provided
