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Health & Fitness Questionnaire

This questionnaire if for individuals seeking one of my personal training and/or private coaching programs. Once you have taken the time to review my programs and services, please return to this page and fill out this questionnaire. Then (if you’d like), reach out by phone or text.

The purpose of this personal health & fitness assessment is to allow for me to understand your present fitness and personal needs to create a tailored and beneficial initial plan for you. Please be as honest and clear with the answers as possible. Your confidentiality and privacy is the utmost importance to me, no one other than me will review this questionnaire.

Take your time. I will review your questionnaire in 1-2 business days, and get back to you with any questions. Once the questionnaire is completed, to expedite the process, you may call or text me at 949.282.4265.

Contact Information
Name*
First Name* Last Name*
Email**
Phone Number**
Instagram Profile
Where Do You Live?**
Fitness Goals
What is your date of birth?
What is your height?
What is your current weight?

Fasted - before eating or drinking in the morning
What are your SHORT TERM health and fitness goals?
What are your LONG TERM health and fitness goals?
What do you feel are your current challenges you are facing which are standing in your way of reaching the above goals?
What are the top questions that come to mind when it comes to reaching your goals, nutrition, fitness, health?*
Exercise
What does your current workout schedule look like?
Do you have any experience weight training? Describe.
What time of day do you workout?
Are there certain types of exercises and training you like or dislike?
Do you have a Gym membership?
- Yes
- No
If yes, which Gym?
If you workout at home, what fitness equipment do you have in your home?
For you, what is the most challenging piece of keeping a consistent exercise program?
Nutrition
Describe your current diet and food choices, write out a sample day with times and amount of food choices.
What is your current daily calorie intake? And daily protein/carbohydrate/fat intake? Are you maintaining, losing or gaining on this intake level?
What are your diet goals?
What has your diet been like the past 6 months? Past 1 year? Past 5 years? Have there been major changes in dietary intake over these time periods?
Foods you tend to crave:
How often do you eat in your day? Do you have set times for eating or restrictions on times due to work/life?
Make a list of your known allergies and food allergy/intolerances.
What experience do you have with cooking and/or prepping your own food?
How would you describe your relationship with food?
Any past or current food eating disorders? Explain.
Do you take any supplements, vitamins, etc? Please list.
Lifestyle
Give me a brief breakdown of your lifestyle and lifestyle stressors.
What time do you wake up and go to sleep?
What are your typical work hours?
Gut Health
Have you been on antibiotics in your lifetime? If so, for what, and when?
Do you find yourself getting sick often? Flu? Colds?
How is your skin? Do you have acne or trouble with acne on your face or body?
Is your digestion regular (1-3 times per day)? Do you get constipated or have diarrhea often?
Do you have bloat or gas often? If so, when do you notice it the most?
Medical History, Conditions and Injury
Do you have any medical aliments, orthopedic injuries, or discomfort in any areas of your body?
What positions or movements that you know of tend to irritate your condition(s)?
What is your health status currently & in the past (List of health conditions/issues)
Do you have a regular menstruation?
Do you suffer from fatigue or lack of energy?
Make a list of any vices, like smoking, etc.
Are you on any medications?
Please include brands and any over the counter medications and birth control.
Please list any aliments, illness or health history that runs in your family.
Phone
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Health & Fitness Questionnaire

Contact Information

Fitness Goals

Exercise

Nutrition

Lifestyle

Gut Health

Medical History, Conditions and Injury

It’s never too late to be fit and fabulous