Welcome! This questionnaire takes about 10 minutes, and is designed to give me some background on your starting point and goals. All answers are confidential. If you're unsure of any questions just give them your best shot.

Date Of Birth

In the format of dd-mm-yyyy

Gender *

Email *

Mobile

Emergency Contact Name

Emergency Contact Number

Do you smoke/vape?

Yes

No

Your goals

What would you like to get from Training? *

You can tick as many as apply

Improve fitness

Lose weight/body fat

Maintain weight

Gain weight

Gain muscle

Get stronger

Look better

Feel better

Have more energy

Develop better control of eating habits

Learn about nutrition

Improve athletic performance

Recover from injury

Physique competition/modeling

Other

Of these, which is the ONE most important to you?

What do you expect?

What do you most want to get from me as your Trainer?

What's worked for you in the past?

Have you tried anything in the past to change your habits, your health, your eating, and/or your body?

If so, what?

Which of those things worked well for you? (Even if you might not be doing it right now.)

Which of those things didn’t work well for you?

How, specifically, would you like your habits, your health, your eating, and / or your body to be different?

What are some of the obstacles that have held you back from changing these things?

Household

Who makes up your household?

Check all that apply

Live alone

Spouse or partner

Child(ren)

Other family

Roommate(s)

Pet(s)

Right now, how much do the people and things around you support health, fitness, and/or behaviour change?

Not at all

They have no opinion

A bit

Completely

Diet and nutrition

Right now, how would you rate your overall eating / nutrition habits?

Awesome

Good

OK

Bad

Horrible

Why?

How would you rate your understanding of food/nutrition right now? (ie. what the main nutrient types are, what foods are healthy, what calories are etc.)

I'm an expert

I have a good everyday understanding of nutrition

I have basic knowledge

I'm not sure

I don't really understand nutriton

How do you feel about preparing and cooking your own meals?

I never cook meals

I can do the basics

I cook most of my own meals

I love cooking & do as much as possible

How often do you eat out/have takeaways or readymeals, including lunch at work?

Once per week or less

Once or twice per week

Once per day

More than once per day

All my meals

Who does most of the grocery shopping in your household?

Check all that apply

Me

Spouse or partner

Child(ren)

Other family

Roommate(s)

Who decides on most of the menus/meal types in your household?

Check all that apply

Me

Spouse or partner

Child(ren)

Other family

Roommate(s)

Who does most of the cooking in your household?

Check all that apply

Me

Spouse or partner

Child(ren)

Other family

Roommate(s)

How often do you consume alcohol?

Not at all

About once a month or less

About once a week

More than once a week

Daily

Activity

How many hours per week are you regularly active in sports and/or exercise?

None

1-2 hours per week

2-5 hours per week

5-9 hours per week

10+

On average, how many hours per day are you active in other ways?

(e.g., housework, walking to work or school, home repairs, moving around at work, gardening)

None

1 - 2 hours per day

2 - 4 hours per day

4 - 8 hours per day

8+

What’s your health like?

How would you rate your overall health right now?

Awesome

Good

OK

Not very good

Poor

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries? *

Yes

No

If yes, please give details

Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries? *

Yes

No

If yes, please give details

Right now, are you taking any medications, either over-the-counter or prescription? *

Yes

No

If yes, please give details

Stress and recovery

In an average week, how many hours do you spend in your main occupation (work/college/parenting etc?)

In an average week, how many hours do you spend travelling and/or commuting?

Given all the demands of your life, what is your typical stress level on an average day?

None

A little stress

OK

Quite a lot of stress

Extreme stress

How do you normally cope with stress?

On average, how many hours per night do you sleep?

4 or less

5

6

7

8

9

10 or more

How ready, willing, and able are you to change?

DISCLAIMER *

Please recognise that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

Initial Assessment