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Accidental Fitness Quest

On a quest for some kind of fitness

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Home→Online Coaching Questionnaire

Online Coaching Questionnaire

Thanks for your interest in an online fitness program. Your answers to the questions below will allow me to get me started creating your program. Rest assured that your answers are completely confidential and will not be shared with anyone. Please keep in mind that the questionnaire does not commit you to purchasing an online program in any way. Based on your answers, I’ll probably have a few follow up questions for you before we get started. I’m looking forward to working with you!

Name *

First and Last Name

Email *

Phone Number

(Optional)

Referred By

If you were referred by someone, please let me know so they get credit.

Age *

Height *

Weight *

Initial Goal *

Do you have specific problem areas or areas that you would like to improve? If yes, please provide details.

Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you undertake an exercise program? *

Yes

No

If yes, I will contact you for details.

Are you under the care of a physician, chiropractor, or other health care professional for any reason? *

Yes

No

If yes, I will contact you for details.

Have you recently experienced any chest pain associated with either exercise or stress? *

Yes

No

If yes, I will contact you for details.

Do you smoke cigarettes? *

Yes

No

Are you under a lot of stress at home, at work, or both? *

At Home

At Work

Both Home and Work

Do you work: *

Full Time

Part Time

Neither

Would you describe your activity level as: *

Intense (on the go most of the day)

Moderate (active off and on with frequent sitting breaks)

Sedentary (mostly seated)

Please describe your current exercise program including type of exercise, frequency, duration, and intensity. *

Please include all types of exercise including cardio, sports, resistance training and other exercise activities. For example, Zumba 3 times per week, run 3 miles twice a week.

Where do you prefer to workout? *

Home

Gym

Both

What equipment do you have available to you? (Check all that apply.) *

Dumbbells

Bands

Gym Membership

Stability Ball

None

Will you be continuing any of your current exercise program after beginning this program? *

Yes

No

How much water do you drink in a typical day? *

What types of food do you typically crave? *

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