Questionnaire Basic Info Your name Telephone No Gender Email Height Weight Goals Please rank the following goals in order of importance, 1 being the most and 7 being the least. Improved health Fat loss Improved endurance Weight gain Improved strength Sports specific Improved muscle mass Please list your specific goals (i.e. amount of weight loss, % of body fat loss, amount of lean muscle etc.) If you have any, what are your specific times frames for achieving your goals? Please tick which type of progress is the most important for you: Immediate progress that is less easily maintainedMaintainable progress that may not be as rapid EXERCISE HISTORY What is your fitness / strength training experiences? BeginnerIntermediateExperienced Do you currently train at least 3 times per week? YesNo Use the following key for the type: resistance training(RT), Interval cardio(INT), Low intensity cardio(LIT), sport specific work(SSW). Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Type Duration If you are not currently training at least 3 times per week, have you ever been on a consistent exercise programme(more than 3 times per week)? YesNo If you have previously exercised on a consistent basis, how long ago was this, and how long did it last? COMMITMENT Are you willing to exercise for at least 5 hours per week? YesNo Do you have a gym membership? If not, are you willing to get one? YesNo Are you willing to spend a minimum of 30 minutes each day preparing your meals? YesNo MEDICAL If you have any diagnosed health conditions, please list your condition(s). If you are currently on any medication(s), please list them. This includes the contraceptive pill. What additional therapies or interventions are being undertaken for the given health problem(s)? Please list any current or previous injuries: Current: Previous: What additional therapies or interventions are being undertaken for your current/old injuries? Do you smoke? YesNo If the answer is yes, how many do you smoke each day? Do you drink? YesNo If the answer is yes,how many units do you drink each week? 175ml glass of wine is 2 units, 1 pint of beer / lager is 3 units I do not drink2-55-10More than 10 units LIFESTYLE What do you do for a living? What level of physical activity is required for your job? NoneModerateHigh Does your job involve shift work? YesNo If you follow a more regular schedule, do you work mornings, days or nights? MorningsDaysNights How often do you travel? RarelyA few times per yearA few times per monthA few times per week Do you have children? YesNo Please indicate the physical activities that you participate in outside of the gym and outside of work How many times do you go food shopping per week? How many times do you eat out per week (includes restaurants and takeaways)? How much money do you spend on supplements per month? If you have any allergies, please list them below: MENSTRUAL CYCLE How old were you at your first menses? Painful YesNo Clotting YesNo Date of last menstrual period: Frequency: Length: Do you currently use contraception? YesNo If yes, what please indicate which form: Non-hormonal CondomDiaphragmIUDPartner vasectomyOther (non-hormonal-please describe) Hormonal Birth control pillsPatchNuva RingOther (please describe) If you are not currently using conception, but have used hormonal birth control in the past, please indicate which type and for how long: Do you experience breast tenderness, water retention,or irritability(PMS) symptoms in the second half of your cycle? YesNo Please advise of any other symptoms that you feel are significant: Are you menopausal? YesNo If yes, what age did your menopause start? DIGESTION Do you suffer from any of the following? Indigestion or heart burn? YesNo Gas or belching? YesNo Constipation? YesNo Diarrhoea? YesNo Are there any foods that make you feel uncomfortable after eating them, if any (please list)? Do you have a sense of fullness after meals? YesNo Do you suffer from bloating 1 hour after eating? YesNo Do you suffer from bad breath? YesNo Do you have less than one bowel movement per day? YesNo Do your muscles become easily fatigued? YesNo JOINT HEALTH Do you suffer from any of the following? Aches and pains in your joints? YesNo Arthritis? YesNo Stiffness or limitation of movement? YesNo Pain or aches in muscles? YesNo Feeling of weakness or tiredness? YesNo GENERAL HEALTH Do you suffer from any of the following? Headaches? YesNo Dizziness? YesNo Stuffy nose? YesNo Chest congestion? YesNo Asthma, bronchitis? YesNo Shortness of breath? YesNo Difficulty breathing? YesNo Frequent illness? YesNo Frequent or urgent urination? YesNo Acne YesNo Hives, rashes, dry skin YesNo Hair loss YesNo Flushing, hot flashes YesNo Excessive sweating YesNo Irregular or skipped heart beat YesNo Rapid or pounding heartbeat YesNo Chest pain YesNo Poor Memory? YesNo Mood swings YesNo Anxiety, fear or nervousness? YesNo Anger, irritability, aggressiveness? YesNo Depression? YesNo Binge eating? YesNo Craving certain foods? YesNo Excessive weight gain? YesNo Compulsive eating? YesNo Water retention? YesNo Do you consider yourself underweight? YesNo Fatigue, sluggishness YesNo Apathy, lethargy YesNo Hyperactivity YesNo Restlessness YesNo SLEEP Do you have trouble falling asleep at night? YesNo Do you have difficulty waking up in the morning? YesNo Do you sleep less than 7-8 hours each night? YesNo Do you wake up once or more in the night? YesNo If you do wake up, what time is it at? 1-3 am3-5 amwake up tired at 5amMany times through the night Do you sleep in a room with any light or noise? YesNo Do you wake up feeling tired? YesNo Do you wake up only with an alarm? YesNo Do you go to bed later than 11 pm? YesNo Do you struggle to fall asleep? YesNo Do you get up earlier than 6 am? YesNo Do you use medications to help you sleep? YesNo 81458
