Health and Fitness Questionnaire

May we send you information via social media?
Current Occupational Status
Please check all that apply:

Medical History and Lifestyle

Medical History:
Medications and Supplements:

History of Body Composition:

Travel Schedule:

What is your family structure?
Average Daily Hours of Sleep

What is your perceived level of stress?

What is your perceived level of stress?Very FrequentlyFrequentlyOccasionallyRarelyWhat's that? I'm on cloud 9What is your perceived level of stress?
When I experience something painful or stressful, I would rate my ability to comfort and soothe myself as:
Have you experienced any life-changing events recently?

Exercise and Movement:

On average, how many days do you train/exercise each week?

Which of these exercise modalities do you engage in and how often?

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How many minutes are your exercise sessions, on average?
What is the intensity of your exercise sessions, on average?

Which activity level best describes you for most days?

This does NOT include exercise; we're looking for general activity levels throughout the rest of your day. You might crush your 1-hour workouts but sit the rest of the day at work, and we need to know this to help determine how many calories you're burning daily.

Which body type do you most closely identify with?

(see image for more information)

Current Diet and Favorite Foods

Daily Hunger Levels

During the week, how many times do you eat a day?
Please select any that describe your current diet.
How many servings of diet soda do you consume daily?
How many servings of sweetener packets (i.e. not sugar) do you consume daily?
How many times a day do you eat outside of the house?
How many times a week do you eat outside of the house?
How many times a week do you eat food NOT cooked at home (i.e. restaurant, fast food, social events, etc.)
Describe your knowledge and interest in cooking.
Where do you shop most frequently for groceries?

How much (times per week) and how often (# of servings) do you consume alcohol and caffeine?

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Describe your relationship with food.

Do you have a history of an eating disorder/disordered eating? (please select all that apply)

Motivation and Mindset

What are your goals? (check all that apply and include any that are not listed)
Motivation/Mindset
Are you currently aware of areas that may be keeping you from reaching your goals?