Pre Screenning Questionnaire

It is important you take a few minutes to answer the following questions. Please ensure that you complete ALL questions listed below. In case of not understanding any of them, please contact your instructor.
The information contained will be confidential and will not be released or revealed to any third party sources without your consent.

Name *
Email Address *
Phone
Country *
Age *
Weight *
Height *
Gender *
Relationship Status *
Please Select One
  • Married
  • Single
  • In a relationship
  • It is complicated
  • Other

Medical history


Have You Ever Been Diagnosed Or Treated For Any Chronic Disease (Including Asthma)? If Yes, Please List Down. *
How did you know about me? *
Have you ever been diagnosed or treated for any other disease that required you to be hospitalised? If yes, please list down. *
Have you ever had ANY surgery or medical intervention of any type, including any type of plastic/asthetic surgery, birth delivery or any other? If yes, please list down. *
Are you currently taking any medications? If yes, please list down and describe what for. *
Are you aware of having any body structure condition such as scoliosis, flat feet...? *
Do you suffer from any chronic pain (bones, joints, muscles…)? If yes, please list down, description of pain, duration and if you have seen a specialist, his diagnosis and suggested treatment. *
Have you ever had any injuries related to physical activity? If yes, please list down, describe how they happened, if you have been seen by a specialist, his diagnosis and suggested treatment. *
Are you aware of any type of exercise or movement that you cannot or should not do? If yes, please which one and the reason if known. *

Lifestyle


What is your occupation? Please describe type of activity. *
What time do you start and finish? *
Does your occupation stress you? If yes, which part stresses you? Example: work load, pressure from management, relationship with workmates… *
Do you have to travel often? If yes, is it for work, leisure or both? How often and how long for? *
How many hours do you sleep per day? What time do you go to sleep and wake up everyday? *
On a scale of 1-10, how would you rate your sleep quality? *
Do you smoke? If yes, how much? *
Do you drink alcohol? If yes, how much and how often? *
Are the people you spend most time with into exercise or healthy habits? *
Please Select One
  • yes
  • no
  • most of them but not all
  • just a few of them
  • half/half
Please describe your daily routine since you wake up until you go to sleep. *

Goals


Do you have any health related goal? If yes, please list down, describe why you want to achieve it and how do you think it will impact your life once you achieve it. *
Do you have any specific goals related to body composition (weight loss, build muscle, etc.)? If yes, please be specific and describe why you want to achieve it, how you think it will impact your life once you achieve it and the time frame in which you want to achieve it. *
Do you have any specific goals related to performance (get better at specific exercise, strength, speed, etc.)? If yes, please list down and describe in detail. please be specific and describe why you want to achieve it, how you think it will impact your life once you achieve it and the time frame in which you want to achieve it. *
Please list down the previous mentioned goals organised by priority or most important first. *
What do you think has stopped you from achieving these goals until now? *

Training Experience


Have you ever participated in resistance, weight training, group class, etc. before? If yes, please list down what type of activities, when and for how long. *
If previous question was yes, what type of activities did you enjoy/like the most and what type you dislike the most? *
Have you ever trained with a personal trainer before? If yes, please explain the experience, in person or online, how was the training delivered, what part you like the most and what part you dislike the most. *

Training preferences


How many training sessions per week will you commit to workout? *
Are you willing and able to perform recommended exercise (i.e. walking, cardio, stretching, etc.) on your own time outside the gym session)? *

Nutrition


Have you ever worked with a nutritionist or used a diet program before? If yes, please explain the experience, results obtained and how long they lasted. *
Do you know how to differentiate what products can provide you with different nutrients such as protein, carbohydrates and fats? *
Do you know how to count Calories? *
Do you know how to use My Fitness Pal application or anyone similar to count macros? *
How many times do you eat per day on average? Please describe *
How much water do you drink per day? *
Apart from water, do you have other drinks on your daily basis (juice, coffee, protein shakes…)? If yes, please describe how much. *
Do you eat fast food? If yes, how often? *
Are you CURRENTLY taking any dietary supplements? If yes, please list, explain what for and why you decide to take them (doctor’s prescription, trainer's recommendation, friend advise, read it was good on magazine…) *
If I recommend you to take any supplement, are you willing to take it? (I only recommend supplements when they are necessary and only if they are back up with scientific evidence) *
Do you have any food allergies? If yes, please list down *
What are your top 3 favourite foods? *
Is there any food that you hate and cannot eat? *

Your current daily meals


- Write with as many details as possible (food, how many grams, what time).
- In case you do not eat any of the meals below, just write nothing.
- Please include the drinks that you have with each meal as well.

Breakfast:
Lunch:
Dinner:
Other meals:
Snacks:

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