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Questionnaire

    Basic Info

    Goals

    Please rank the following goals in order of importance, 1 being the most and 8 being the least.

    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:

    EXERCISE HISTORY

    What is your fitness / strength training experiences?

    Do you currently train at least 3 times per week?

    Use the following key for the type: resistance training(RT), Interval cardio(INT), Low intensity cardio(LIT), sport specific work(SSW).

    DayMondayTuesdayWednesdayThursdayFridaySaturdaySunday
    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)?

    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?

    Do you have a gym membership? If not, are you willing to get one?

    Are you willing to spend a minimum of 30 minutes each day preparing your meals?

    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?

    If the answer is yes, how many do you smoke each day?

    Do you drink?

    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

    LIFESTYLE

    What do you do for a living?

    What level of physical activity is required for your job?

    Does your job involve shift work?

    If you follow a more regular schedule, do you work mornings, days or nights?

    How often do you travel?

    Do you have children?

    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

    Clotting
    Date of last menstrual period:
    Frequency:
    Length:

    Do you currently use contraception?

    If yes, what please indicate which form:

    Non-hormonal

    Hormonal

    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?

    Please advise of any other symptoms that you feel are significant:

    Are you menopausal?

    If yes, what age did your menopause start?

    DIGESTION

    Do you suffer from any of the following?

    Indigestion or heart burn?

    Gas or belching?

    Constipation?

    Diarrhoea?

    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?

    Do you suffer from bloating 1 hour after eating?

    Do you suffer from bad breath?

    Do you have less than one bowel movement per day?

    Do your muscles become easily fatigued?

    JOINT HEALTH

    Do you suffer from any of the following?

    Aches and pains in your joints?

    Arthritis?

    Stiffness or limitation of movement?

    Pain or aches in muscles?

    Feeling of weakness or tiredness?

    GENERAL HEALTH

    Do you suffer from any of the following?

    Headaches?

    Dizziness?

    Stuffy nose?

    Chest congestion?

    Asthma, bronchitis?

    Shortness of breath?

    Difficulty breathing?

    Frequent illness?

    Frequent or urgent urination?

    Acne

    Hives, rashes, dry skin

    Hair loss

    Flushing, hot flashes

    Excessive sweating

    Irregular or skipped heart beat

    Rapid or pounding heartbeat

    Chest pain

    Poor Memory?

    Mood swings

    Anxiety, fear or nervousness?

    Anger, irritability, aggressiveness?

    Depression?

    Binge eating?

    Craving certain foods?

    Excessive weight gain?

    Compulsive eating?

    Water retention?

    Do you consider yourself underweight?

    Fatigue, sluggishness

    Apathy, lethargy

    Hyperactivity

    Restlessness

    SLEEP

    Do you have trouble falling asleep at night?

    Do you have difficulty waking up in the morning?

    Do you sleep less than 7-8 hours each night?

    Do you wake up once or more in the night?

    If you do wake up, what time is it at?

    Do you sleep in a room with any light or noise?

    Do you wake up feeling tired?

    Do you wake up only with an alarm?

    Do you go to bed later than 11 pm?

    Do you struggle to fall asleep?

    Do you get up earlier than 6 am?

    Do you use medications to help you sleep?

    FOOD DIARY

    Please complete the food diary below. Please complete one day as a minimum.

    This is a very important part of your application process. Your consultation will only proceed if this section has been completed fully(one day food diary as a minimum).

    • Energy levels – please include your current energy levels before and after each meal. Use L / N / H to indicate low / normal / high

    • Please indicate your portion sizes. Use S/M/L to indicate small/medium/large

    DayFoodTimePortion sizeEnergy beforeEnergy after
    Meal / snack 1
    Meal / snack 2
    Meal / snack 3
    Meal / snack 4
    Meal / snack 5
    Meal / snack 6