Questionnaire

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INITIAL QUESTIONNAIRE

First Name *
Last Name *

Date of birth *

Height *

Current Weight *

Goal Weight *

ACTIVITY ASSESSMENT

Please select your current activity level: *

Sedentary - Desk job, Little to no exercise Little Activity - Exercise moderate 1-2 days a week Moderate - Exercise moderate 2-3 times a week Active - Physical Work, Exercise hard 5+ days a week Highly - Physical Work, Exercise very hard 6-7 days a week

Have you attended a commercial gym before? *

Yes No

How many days per week do you currently attend the gym? *

Please list your 3 main goals:

GOAL 1 *

GOAL 2 *

GOAL 3 *

What forms of exercise have you completed in the past? - Please list the injury and any limitations this imposes... *

Do you currently have any injuries? If so, please list and explain what movements aggravate it *

Equipment Accessibility

Please select from the lists below which of the following you have access too:

Weights

Cardio

Machines / Accessories

List any additional equipment if not mentioned above

NUTRITION ASSESSMENT

In this nutritional assessment, our goal is to have a clear and accurate idea on what types of foods you are consuming. In order to maximise results, we ask you to be 100% accurate through this assessment.

Have you been on a Nutritional Plan before? *

Yes No

If yes, please explain in detail what you found to be the biggest challenges

How much water do you drink per day?

How often do you consume dairy products? *

List the dairy products you consume (if any)

How often do you consume wheat products? *

List the wheat products you consume (if any)

How often do you eat Fresh/Frozen Fruit *

List the fruits you consume (if any)

How often do you consume vegetables? *

List the vegetables you consume (if any)

Do you use artificial sweetener in beverages *

Yes No

Cups of coffee per day *

Cans of soft drink per day *

Cups of green tea per day *

How often do you consume sugary drinks? (i.e. fruit juice/soft drink) *

List the sugary drinks you consume

How often do you consume alcohol? *

Do you smoke cigarettes? *

Yes No

If yes, how many per day?

Do you have any known food allergies? *

Yes No

If yes, please provide details of your food allergies

List all the supplements you are currently taking (if any)

List all the medications you're currently taking including dosage (including birth control)

What time of day are you most energetic? *

What time of day are you least energetic? *

What blood type are you? A, AB, B, O? *

Nutrition Diary:

Over the next 2 days, please document every item you consume in the app TrueCoach. (no matter how small, it must be recorded). Things to include: soft drink, olive oil, chocolate, nuts, milk in coffee. Everything that is consumed.

This is an exercise of honesty, so please do your best to complete this as honestly as possible.

If eating out, please do your best to list as much info about the meal as possible.

WELLBEING ASSESSMENT

The following is the final assessment we will need to go through before we can properly prescribe your new lifestyle plan. As with the other assessments, we urge you to please be 100% accurate in explaining your current situation.

In 1 - 3 words, describe how you feel when:

You don't work out in a day *

You eat something not listed on your nutrition plan? *

You resist temptation when out for dinner *

Someone comments on your weight in a positive way *

Someone comments on your weight in a negative way *

How many hours of sleep do you get per night? *

Which of the following apply?

Cancer

Diabetes

Heart Disease

High Blood Pressure

High Cholesterol

Hyperglycemia

Obesity

Osteoporosis

Do you perform any sort of Meditation or Relaxation *

List the 3 biggest stressors in your life:

Stressor 1 *

Stressor 2 *

Stressor 3 *

Have you lost large amounts of weight before?

Whether yes or no, please describe how you feel about your answer. If yes, please give details on when, how much, how you lost it, and has it been put back on? *

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