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Comprehensive Client Information Questionnaire
This is your comprehensive client information sheet, in which we will ask you to provide
some relevant personal information. The answers to these questions are essential in order
to allow us to design an optimized individual fitness program for you. Please answer all
questions in the most accurate manner possible while being as concise as possible.
DISCLAIMER
Please recognize the fact that it is your responsibility to work directly with your physician
before, during, and after seeking fitness consultation. As such, any information provided
is not to be followed without the prior approval of your physician. If you choose to use this
information without the prior consent of your physician, you are agreeing to accept full
responsibility for your decision.
* Indicates required question
Name
*
Your answer
Date of Birth
MM
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DD
/
YYYY
Today's Date
MM
/
DD
/
YYYY
Do you have any physical limitations, health issues, or injuries that I should be aware of when planning exercise or performance assessments?
Write "N/A" if none.
Your answer
Do you have any food allergies, reactions, or medications that react with certain foods that I should be aware of before discussing nutrition options?
Write "N/A" if none.
Your answer
My current diet could be best characterized as:
Check all that apply
Low-fat
Low-carb
High-protein
Vegetarian/Vegan
No special diet
How many meals do you typically eat daily?
May be smaller, more frequent meals or less frequent larger meals
Your answer
How many meals do you eat in restaurants and/or fast food places per week?
Your answer
How many pre-packaged (purchased/microwaveable) meals do you eat per week?
Your answer
How many meals do you prepare at home per week?
Your answer
Describe your living scenario and social setting for meals at home and/or with friends.
Do you live alone, with a spouse/significant other, or with friends? Do you have children and do they eat the same meals as you? Do you choose meals for your family based on what the other family members will like or what you think is healthy? Do you usually eat by yourself or with others at home? Do you usually prepare the food or does someone else prepare the food in your home? Do you feel you should eat a certain way based on others or based on the social setting you're in? Who purchases the food in the home? Do you share expenses/food with others in the home?
Your answer
Describe your meal scenario/social setting at work.
Do you eat by yourself or with co-workers? Do you eat while you work or do you separate your meal/break times from work? Do you feel obligated to go out to eat with co-workers or eat similarly to co-workers? Do you have to grab food on the go due to work or travel? Do you keep snacks at your desk or workplace and if so what types? Do you have office meals/potlucks and how frequently? Do you or co-workers bring in shared food items? Does your job involve business transactions over meals or social gatherings?
Your answer
Are there any diets or meal plans that you feel were successful with reaching your goals in the past?
Your answer
Are there any diets or meal plans that you feel were unsuccessful or resulted in the opposite of your goals in the past?
Your answer
Are you taking any nutritional supplements? Please list them below (type and dosage).
Your answer
Please describe your general routine on the weekdays.
Include wake time, bedtime, work hours, meal times, exercise time, socializing activities, commitments, etc.
Your answer
Please describe your general routine on the weekends.
Include wake time, bedtime, activities, outings, travel, socializing activities, exercise, meal times, etc.
Your answer
What is your activity level at your job?
Choose
None (seated work only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you work an irregular work schedule?
Ex: shift work, night shift, rotating
Your answer
Are you currently exercising regularly (at least 3x per week)?
Yes
No
Clear selection
How long have you been consistently exercising without an extended break?
Please provide approximate timespan or write "Not currently exercising"
Your answer
In a week, how many days would you say you perform resistance training exercises?
Ex: Strength workouts, powerlifting, olympic lifting, weight-training, resistance bands, performance with load, etc
Choose
0 days
1-2 days
3-5 days
6-7 days
In a week, how many days would you say you perform interval cardio bouts?
Ex: Stations, sprint intervals, short bursts of work/rest, tabata training, etc
Choose
0 days
1-2 days
3-5 days
6-7 days
In a week, how many days would you say you perform low-intensity cardio bouts?
Ex: walking, jogging/running, swimming, rowing, biking, activity that lasts longer than 20 minutes at a steady pace
Choose
0 days
1-2 days
3-5 days
6-7 days
In a week, how many days would you say you perform sport-specific work or play a recreational sport?
Ex: soccer, hockey, basketball, football, softball, or training related to these sports specifically
Choose
0 days
1-2 days
3-5 days
6-7 days
Please describe typical weekly exercise or physical activities (type and duration) including any exercise at work.
Your answer
Check all the exercises below that you are VERY familiar with
Ex: Would not need a demonstration of the movement and would feel confident with the movement
Running
Walking
Jumping Rope
Rowing (Using machine)
Using treadmill
Using elliptical machine
Using stationary bike
Using stair climber
Using resistance bands
Kettlebell swings
Squatting with a barbell
Bench Press with a barbell
Overhead press with a barbell
Deadlift with a barbell
Snatch with barbell
Clean with barbell
Air Squats (Without barbell)
Push Ups
Pull Ups
Sit Ups
Burpees
Mountain Climbers
Check all the exercises below that you are SOMEWHAT familiar with
Ex: Would need a reminder of the movement
Running
Walking
Jumping Rope
Rowing (Using machine)
Using treadmill
Using elliptical machine
Using stationary bike
Using stair climber
Using resistance bands
Kettlebell swings
Squatting with a barbell
Bench Press with a barbell
Overhead press with a barbell
Deadlift with a barbell
Snatch with barbell
Clean with barbell
Air Squats (Without barbell)
Push Ups
Pull Ups
Sit Ups
Burpees
Mountain Climbers
Check all the exercises below that you are UNFAMILIAR with
Ex: Would need in depth demonstration, review of movement, and coaching throughout movement
Running
Walking
Jumping Rope
Rowing (Using machine)
Using treadmill
Using elliptical machine
Using stationary bike
Using stair climber
Using resistance bands
Kettlebell swings
Squatting with a barbell
Bench Press with a barbell
Overhead press with a barbell
Deadlift with a barbell
Snatch with barbell
Clean with barbell
Air Squats (Without barbell)
Push Ups
Pull Ups
Sit Ups
Burpees
Mountain Climbers
What is your ideal exercise setting?
Check all that apply.
Alone
With 1 or 2 friends
In a large group
Following a personalized plan
Group class with instructor
Typical gym setting using cardio machines
Typical gym setting using strength machines
Free weights
Outdoors
While listening to music
While watching television/movie
While reading
Short exercise sessions (less than 15 minutes, possibly multiple times per day)
Long exercise sessions (more than 20-30 minutes)
Given the following goals, please check the three (3) that are most important to you.
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
Increased power
Weight-gain
Sport-Specific
Do you have a specific target date for achieving a specific goal?
If no, please leave blank.
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