2110 Client Consultation Questionnaire

1
Full Name* This field is required.
First Name
Last Name
2
Phone Number
Area Code
Phone Number
3
Email
example@example.com
4
Date of Birth* This field is required.
Month
Day
Year
5
Age
Years
6
Height
ft/in
7
Weight
lbs
8
Resting Heart Rate
BPM
9
Blood Pressure
mm Hg
10
Body Fat %
Percentage
11
Do you have any concerns regarding fitness activity i.e.) health risks/injuries/concerns?
12
What is your training age (years you have been exercising) and at what frequency do you train?
13
What would you like to achieve with an exercise program?Check all that apply
Lose Weight
Gain Weight
Decrease Body Fat
Increase Muscle Mass
Increase Definition
Health Benefits
General Fitness
Feel Better
Sleep Better
Reduce Stress
Injury Rehab
Sport Specific Performance Gains
Increase Muscle Strength
Increase Aerobic Fitness
Increase Flexibility
14
Timeline for achieving your goal.
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
WHEN
WHEN
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
15
How often are you willing to train a week to reach your goal?
16
What kind of activities do you enjoy (or are willing to try)? Check all that apply.
Outdoor Cardio
Indoor Cardio
Walking
Olympic Lifting
Group Classes
Weight Training
Yoga
HIIT/Interval Training
Outdoor Activities
17
What kind of activities do you enjoy that were not listed above?
18
Do you take any medications or supplements?
19
Do you have any dietary restrictions or sensitivities?
20
Do you have any food preferences (dislikes or favorites)?
21
Do you have any preferred styles of eating or dietary patterns you adhere to (eg. Macro Counting, Intermittent Fasting, Keto...)?
22
On a scale of 1-10 (10 being excellent, 1 being poor), how would you rate your sleep?
1
2
3
4
5
6
7
8
9
10
23
Please describe your quality of sleep.
24
On a scale of 1-10 (10 being high, 1 being low), how would you rate your stress?
1
2
3
4
5
6
7
8
9
10
25
Please describe the sources of your stress.
26
Were you referred to us? If so, by who?If you were not referred to us, please feel free to leave this blank.
27
I AGREE TO THE FOLLOWING TERMS & CONDITIONS!* This field is required.1.) CANCELLATIONS Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client. 2.) LATE ARRIVALS Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client. 3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
Yes
No
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