TRAINING QUESTIONNAIRE

Please fill out the questionnaire below in as much detail as possible so I can see how to best help you.


Personal Details
Name *
Name
Date of Birth *
Date of Birth
Phone
Phone
Personal Medical History
Do you feel pain in your chest when you do physical activity *
If you answered YES, please provide more information
Do you lose your balance because of dizziness, or have you ever lost consciousness? *
If you answered YES, please provide more information
Do you or have you ever had a soft tissue injury including bone or joint problems? *
If you answered YES please list the condition(s) including any previous injuries or surgeries. Please also list any additional therapies or interventions are being undertaken for the given injury(s)?
Have you been diagnosed with any health problems including any heart conditions? *
If you answered YES, please list the condition(s) and provide any additional information.
Do you occasionally use or are you currently taking any prescription or over-the-counter medications *
this also includes blood pressure, heart medication, antihistamines or diuretics
If you answered YES, please go list all medications and provide any additional information.
Do you know of any other reason why you should not do physical activity? *
If you answered YES, please provide more information
Goals and Exercise History
What are you goals? *
Given the following goals below, please check all boxes that apply
* If you selected Athletic performance please describe your sport and the support you require
What do you want to achieve over the next 3 months? Take your time to think about this and be as specific as you can, providing as much detail about each goal.
What do you want to achieve by this time next year? Spend a bit more time on this and try to think about realistic goals that you feel with some support you'd like to challenge yourself with.
This can feel like a bit of an open question so try to pick some of your most common thoughts.
Are you currently exercising regularly (at least 3x per week)? *
Provide the exercise type, times, duration and intensity levels of each activity. Also include any exercise you may do at work.
Lifestyle & Nutrition
How often do you travel?
Do you have any food allergies, intolerances or avoidances? *
If you answered YES, please provide more information
My current diet could be best characterised as: *
Please check all that apply
* If you selected OTHER, please explain in more detail.
Are you experiencing any stresses, mood problems, relationship difficulties, or substance-related problems for which you would like resource or referral information on a confidential basis? *
Right now, how would you rank your overall eating / nutrition habits? *
Right now, how would you rank your overall eating / nutrition habits?
I have complete control over all aspects of my nutrition
Right now, how much do the people and things around you support health, fitness, and / or behavior change? *
Right now, how much do the people and things around you support health, fitness, and / or behavior change?
I have the full support from my friends/family to make there changes I need.
How do you feel about your schedule, time use, and overall busy-ness *
How do you feel about your schedule, time use, and overall busy-ness
My Life is perfectly cam and relaxed
Given all the demands of your life, what is your typical stress level on an average day? *
Given all the demands of your life, what is your typical stress level on an average day?
I have no stress and things are pretty good.