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Health &
Fitness Questionnaire
The information requested gives us an understanding about our client's attitudes towards health and fitness. By gathering proper information, we can customize our client's training for maximum safety and effectiveness. All personal information will be keep
confidential
Name (Last, First)
Email
Please answer every question honestly. We will be going over this together during your orientation.
What did you weigh in high school?
Were you athletic in high school?
Yes No
Were you athletic in college?
Yes No
Compared to your fitness level in high school, are you currently...?
Have you ever started and stopped a fitness program?
Yes No
If yes, why did you stop?
What type of physical activity are you currently engaged in?
(Include any exercises, sports, or recreational activities. If you have a gym membership, what gym do you go to?)
How long have you participated in this activity?
How many times per week?
How would you rate your current level of fitness?
Have you ever been on a diet? Yes
No
Are you currently on a diet? Yes
No
Do you currently use, or have you ever used, any diet shakes, bars, or pills?
Yes No
If yes, please specify the kinds of products and your results
If no, are you opposed to using any meal replacement products?
Yes No
Are you satisfied with your current eating habits?
Yes No
How many meals do you eat a day?
Do you eat breakfast?
Yes No
Do you eat meat (beef, chicken, pork, fish, etc.)?
Yes No
Do you read food labels?
Yes No
Do you snack?
Yes No
What are your favorite snacks?
Do you ever "treat" yourself with food?
Yes No
What are your favorite foods?
Do you have any dietary restrictions or food allergies?
Please list
Do you drink alcohol?
Yes No
If yes, what do you drink and how much?
Hot much coffee do you drink?
How much tea (hot and/or iced) do you drink?
How much soda do you drink?
Do you use any recreational drugs?
Yes No
Do you smoke/have you ever smoked?
If you smoke, do you want to quit?
Yes No
How many hours of sleep do you get per day?
How would you describe the quality of your sleep?
Have you ever suffered from insomnia?
Yes No
If yes, please explain the circumstances of your insomnia
What time do you wake up in the morning?
Do you work or attend school?
How many hours per day?
What do you do? / What is your major?
Are there any other habits you would like to change?
How long have you been thinking about getting in shape?
How often will you be able to work out per week (whether with or without us)?
Will your friends and family be supporting you in your efforts to get in shape?
Yes No
Are there people in your life who either intentionally or unintentionally discourage you or interfere with your exercise and nutrition program?
Yes No
Have you ever seen:
Do you have any negative feelings toward physical activity programs?
Have you ever had a bad experience with a physical activity program?
What is your present level of commitment to reaching your fitness goals?
You need to create a clear, tangible image in your mind of the benefits of staying on your fitness program. It must be vivid and powerful enough to sustain you through difficult times when you feel your self-discipline and motivation slipping. This exercise will help you create that image.
How much do you agree? (Choose one)
Exercise will...
Improve my appearance
Allow me to cope with stress better
Help me avoid getting sick
Give me a powerful sense of personal achievement
Increase my self-esteem
Improve my physical strength
Make me more independent
Improve my ability to concentrate
Take up too much time
Cause pain, soreness, and discomfort
Make me very tired
Cause me to get injured
What do you want exercise to do for you?
What areas of your body do you specifically want to work on?
In your own words, please take a minute and consider why you want to achieve these goals.
(This is the single most important question on this form.)
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