Health Survey
Please fill out this health survey for your own good and the good of others!
Name
First Name
Last Name
Email
example@example.com
Phone Number
Mobile Number of form user: We will send you your PT option via phone
Fitness
Let's dive into your fitness and movement.
Do you do any exercise (in gym/outside/sports etc)?
1 - 3 a week
3 - 5 a week
Everyday
Never
Which of the following best describes your training/exercise?
Weights
Cardio
Functional Fitness
Personal Training
Walking/Running
Sports
Don't really do that much...
Other
How would you rate your fitness levels now out of 5?
1
2
3
4
5
What times would you prefer to exercise?
Morning
Afternoon
Evening
Night time
Never :)
Weekends only
Highlight some outcomes you'd like to see in your own fitness
Improved Mobility/Movement
Better Fitness
Improved Strength
Better Lifestyle
Get Toned
Become a part of a community
Better Mental Clarity/Mental Health
Stress Reliever
Perform Better at Sport
Other
Lifestyle
Let's look into your broader world
Do you smoke?
1 Pack/day
2 Packs/day
+3 Packs/day
No
Every so often
1 - 4 Packs per week
Do you drink alcohol?
Daily (small amounts)
Weekends only
Every so often
No, never
Very often
How much coffee do you drink?
Don't drink coffee
1 Cup Per Day or less
Every so often
2-3 Cups per day
3-5 Cups per day
I am practically made of coffee...
How many hours do you sleep?
Less than 5 hours
5 - 6 hours
7 - 8 hours
9 - 10 hours
More than 10 hours
Is your job very active? (Not often seated/active)
1
2
3
4
5
How stressful is your job?
1
2
3
4
5
How happy do you feel now?
1
2
3
4
5
Nutrition
How many serves of fruit and veg would you have per day?
None
1 Serve or less
Hate Veg/Fruit!
2 Serves or more
3-5 Serves per day
5 Serves + per day
What does your breakfast look like?
Big breakfast; the works
Small breakfast on the go or every so often
Just a coffee
Simple smaller breakfast
Other
Do you take any of the below?
Protein Powders
Vitamins
Natural Herbs
Pre workouts
None
How strict if at all do you follow a 'diet'?
1
2
3
4
5
Do you think you would benefit from some nutritional guidance, help, meal guides etc...?
Yes
No
Maybe
Fitness in the Workplace
Let's get active at work!
Would you like to see more local health and wellness initiatives?
Yes
No
Which areas do you think your company/business could benefit from?
Team training sessions
Gym access
Lunch time classes
Monthly seminars on all things health
Online training tools/ideas to do at home
Nutritional Support
Fun Fitness Challenges
Other
Should be Empty: