Background Information

Personal Data (I require your gender and date of birth for personalising your meal plans or workout programs

1. What is your name?

2. Date of birth?

3. Gender? MaleFemale

4. Email?
   

5. Phone number?

6. MetricImperial

Body Statistics

7. Height?
   5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"

8. Weight?
   100-131101-134103-137105-140108-144111-148114-152117-156120-160123-164125-148127-151129-155131-159

9. Body fat?
   Essential fatAthletesFitnessAverageObese

10. 10 Activity level?
    Sedentary (office worker getting little or no exercise)Moderately active (you exercise but get less than 2.5 hours a week of moderate aerobic activity)Vigorously active ( A person exercising for 2 hours, 3-4 times a week)

Fitness Options

10. BeginnerIntermediateAdvanced

11. 11.Location Preferences
    GymHome (home workouts require dumbbells)

Your Goals

12. Why did you decide to apply for a training program?
    

13. Are you satisfied or dissatisfied with your appearance or weight?
    

13. What are your goals?
    

14. Is there a particular part of your body you would like to focus on?
    

15. When do you hope to achieve this goal?
    

16. How many days per week do you hope to exercise?
    

17. Why did you specifically choose me as a coach?
    

19. 19.Why do you think you would make a good client?
    

Nutrition

20. Have you ever gone on a diet? If so, which one/s?
    

21. a. Did any of these diets work to get the results you wanted?

22. What was the best part of this diet?

22. Do you currently skip meals? If so, which ones?

23. Do you snack through out the day? If so, on what?

24. Do you dine out frequently? If so, how often?

What type of food do you eat most frequently while dinning out (i.e. pizza, Italian,

Mexican)?

25. Do you take any nutrition supplements, vitamins or minerals?

26. How much water to you drink on a daily basis?

27. What kind of fats do you consume?
    Shortening or butterVegetable oilCanola or Olive oilSoft tub margarine or low fat?Other

28. How many times per week do you consume a sugary snack or dessert?

29. How many times per week do you consume red meat or chicken?

30. How many times per week do you consume tuna, salmon or other deep ocean fish?

31. Have you ever had a fitness coach before? If so, were there any bad experiences?

32. How did you hear about Kwapsy Fitness? InstagramFacebookInternet searchOther

Health Readiness Questionnaire

Please answer all the following questions to the best of your ability and knowledge.

Section 1

Have you ever had any of the following?

Heart attack or heart failure? YesNo

Heart Surgery YesNo

Metabolic diseases? YesNo

A pacemaker or other heart device? YesNo

A heart valve or congenital heart disease? YesNo

Pulmonary disease? YesNo

A Stroke YesNo

Coronary Artery Disease? YesNo

If you are a woman, are you pregnant? YesNo

Musculoskeletal or nerve problems? YesNo

Section 2

Have you ever experienced any of the following?

Pain in your chest, neck or jaw? YesNo

Shortness of breath with mild exertion? YesNo

Palpitations, tachycardia, or irregular heart beat? YesNo

Orthopnea or Paroxsomal Nocturnal Dyspnea YesNo

Intermittent claudication or thrombosis? YesNo

Ankle swelling? YesNo

Heart murmur? YesNo

Dizziness? YesNo

Section 3

Indicate if you have had any of the following or if any apply to you:

You are a male older than 45 years of age. YesNo

You are woman over 55 years of age or have had a hysterectomy or are postmenopausal. YesNo

You smoke or have quit smoking in the last 6 months. YesNo

You have blood pressure greater than 140/90. YesNo

You are physically inactive or get less than 30 minutes of physical activity on at lest 3 day per week. YesNo

You have total cholesterol greater than 200 mg/dL. YesNo

You have a close male blood relative who had a heart attack before age 55 or a close female relative who had a heart attack before age 65.YesNo

You have diabetes or take medication to control blood sugar. YesNo

Take prescription medication. YesNo

You are more than 20 pounds overweight. YesNo