Intake Questionnaire

Questionnaire: In order to assist in building the best fitness, nutrition, and/or running plan for you, it is necessary to evaluate some of your health, nutrition, and/or lifestyle history, as well as your past and present fitness habits. Please answer all questions to the best of your ability. Your information will be kept confidential, and this questionnaire is used only in helping make plan recommendations.


Contact Information

Name:*
E-mail:*
Address:
Phone:*
Preferred Contact Method:
Preferred Contact Time:
Basic Information

Age:*
Sex:*
Height:*
Weight:*
Nutrition Information

On a scale of 1-10, 1 being poor and 10 being perfect, how would you rate your current diet?*

List 3 areas of your nutrition that you would like to improve:

Area 1:*
Area 2:*
Area 3:*
How many meals do you eat, on average, per day?*
How many snacks do you eat, on average, per day?*
How many glasses of water do you drink, on average, per day?*
How many calories do you eat, on average, per day (if known)?*
Do you have a habit of skipping meals?*
Do you have a habit of skipping breakfast?*
Do you eat late at night before bed?*
Do you wake from sleep to eat throughout the night?*
How many times do you eat out, on average, per week?*
At work and/or school, do you typically bring food or eat out?
Do you do your own grocery shopping?*
Do you do your own cooking?*
Do you eat while engaging in other activities (i.e. watching television, reading, studying, etc.).*
If so, what activities do you eat during?
Besides hunger, what other factors influence you to eat:*
Do you feel drops in your energy level throughout the day?*
If so, when?
Do you eat to the point of fullness?*
Do you eat PAST the point of fullness?*
Do you eat foods that are high in fat?*
Do you eat foods that are high in sugar?*
Do you eat foods that are high in carbohydrates?*
What foods do you typically crave?*
Are you currently taking any multivitamins, vitamins, food supplements, nutritional aids, or meal replacements? If so, please list:
Do you have a history of gastrointestinal disturbances, digestive disorders, or food sensitivities/allergies? If so, please list:
Physical Activity Readiness Questionnaire (PAR-Q)

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*
Do you feel pain in your chest when you perform physical activity?*
In the past month, have you had chest pain when you were not performing any physical activity?*
Do you lose your balance because of dizziness or do you ever lose consciousness?*
Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*
Do you know of any other reason why you should not engage in physical activity?*
If you have answered “yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you have answered “yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Health Information

Rate your current state of health:*
Please elaborate on your choice:
Past and/or present injuries:*
If yes, please explain:
Past and/or present surgeries:*
If yes, please explain (2):
Past and/or present medications:*
If yes, please explain (3):
Past and/or present chronic disease (such as coronary heart disease, coronary artery disease, hypertension AKA high blood pressure, high cholesterol, diabetes, etc.):*
If yes, please explain (4):
Are you currently overweight?*
Have you been overweight in the past?*
If so, what ages?
Is anyone in your family overweight?*
If so, who?
Are you currently pregnant?*
Have you given birth within the past 6 months?*
Family history of illness:*
List what family member and what specific illness:
Training Information

Describe your personal training interests:*
How often do you exercise?*
On a scale of 1-10, 1 being not intense at all and 10 being extremely intense, how would you rate the intensity of your workouts?*
How long have you been regularly physically active for?*
What activities do you currently engage in?*
When were you in the best shape of your life?*
What were you doing when you were in the best shape of your life?*
What, if anything, stopped you from continuing that fitness regimen?*
Describe your “typical” workout:
Describe your “preferred” workout:
Do you have any special scheduling considerations (i.e. “I work late on Mondays so workouts are difficult for me that day” or “I don’t have a sitter for the kids on Wednesdays so I’d prefer that to be a rest day”)?
Do you prefer to exercise indoors or outdoors?*
Do you prefer to exercise alone or with others?*
When do you prefer to exercise?*
Where do you prefer to exercise?*
Realistically, how many times per week would you like to exercise?*
Realistically, how much time per session would you like to exercise?*
What are the best days during the week for you to commit to exercise?*
Please list some of your favorite activities, exercises, etc.:*
Lifestyle Information

Do you smoke?*
If so, how many packs per day or per week?
Do you drink alcohol?*
If so, how many drinks per day or per week?
How many hours, on average, do you sleep per night?*
Do you have trouble falling asleep and/or staying asleep at night?*
Do you typically wake feeling well-rested?*
Do you engage in any recreational activities (i.e. golf, tennis, skiing, hiking, etc.)? *
If so, please describe:
Do you engage in any hobbies (i.e. reading, gardening, working on cars, web surfing, etc.)?*
If so, please describe (2):
Occupation:*
Please describe your job:*
Does your job require travel?*
Does your job cause you stress, anxiety, and/or depression?*
Does your job require repetitive movements? *
If so, please describe (3):
Does your job require you to wear shoes with a heel (i.e. dress shoes)?*
On a scale of 1-10, 1 being very low and 10 being very high, how would you rate your stress level?*

List your 3 biggest sources of stress:

Stress 1:*
Stress 2:*
Stress 3:*
Fitness Resources

Do you have access to a gym?*
Do you have access to any fitness equipment?*
If so, please list:
Do you have access to a track (note: most schools have tracks available for public usage)?*
Do you have access to a park?*
Do you belong to any fitness groups?*
Do you use any fitness technology (i.e. smartphone app, fitness monitor, etc.)?*
If so, please list (2):
Do you wear any orthotics (i.e. shoe insoles, knee brace, ankle brace, etc.)?*
If so, please list (3):
What type of shoes do you wear while working out?*
Running Information

Running interest (check all that apply):*
Describe, in depth, your current training goals. What are you trying to accomplish? When would you like to accomplish this?
How long have you been running?
How many miles per week have you averaged over the past three months?
Have you ever done “speed” workouts, “effort” sessions, or interval training?
If so, please describe (4):
Would you consider yourself a novice runner or an experienced runner?
Most recent racing results (including distance, pace and/or time, and date):
What time of day do you typically run?
Do you prefer to run alone or with others?
Describe your “typical” running route:
Describe your “preferred” running route:
Do you have any special scheduling considerations (i.e. “I work late on Mondays so long runs are difficult for me that day” or “I don’t have a sitter for the kids on Wednesdays so I’d prefer that to be a rest day”)?
Do you engage in any form of cross-training (note: cross-training is defined as activities that closely mimic running form; i.e. swimming, biking, elliptical, stair stepper)? If so, describe:
Do you practice any other form of exercise? If so, describe:
Do you use any running technology (i.e. smartphone app, fitness monitor, etc.)? If so, describe:
Describe any obstacles you feel you might face while run training (i.e. lack of motivation, risk of over-training, absence of support, fear of injury, etc.):
Do you use any nutritional aids for running purposes (gels, bars, tabs, chews, drinks, etc.)? If so, please describe what and when:
Do you have a history of gastrointestinal disturbances related to running?
Running shoes (brand, model, type; i.e. Brooks Cascadia Trail):
Running shoe mileage (if currently known):
Orthotics (i.e. shoe insoles, knee brace, ankle brace, etc.):
Goal Setting

Note: Fighter Fitness recommends following the ‘SMART’ protocol to ensure your success:

S=Specific (provide specific details; how long, how much, how often, etc.)
M=Measurable (describe how you will measure whether you’ve reached your goals)
A=Attainable (be realistic in what you want to achieve; break larger goals into smaller goals)
R=Rewards-Based (attach a reward to each goal; do not reward good behaviors with bad behaviors)
T=Time Frame (set a specific date for your goal)

Vague Goal: I want to lose weight.
‘SMART’ Goal: I will exercise for at least 30 minutes for 5 days a week. My goal is to lose 2 pant sizes within 3 months, and when I do I will reward myself with a new fitness monitor.

Vague Goal: I want to be stronger.
‘SMART’ Goal: I will strength train for at least 45 minutes for 4 days a week. My goal is to increase my weights by 10% over 6 months, and when I do I will reward myself by going to a concert.
Please list, in order or priority, the fitness goals you would like to achieve within the next 3-12 months:
Goal 1:*
Goal 2:*
Goal 3:*
How will you feel once you’ve achieved these goals? Be as specific as possible.*
What do you fear could possibly prevent you from achieving these goals (i.e. lack of motivation, upcoming holiday, busy season at work, inconsistent training, responsibilities to family, etc.)? Be as specific as possible.*
How committed are you to achieving your fitness goals?*
How much of a priority is your overall health?*
What do you feel is the most important thing your personal trainer could do to help you achieve your fitness goals?*

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