APP Personal Training Lifestyle Questionnaire Survey

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* 1. Client Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Age

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* 3. Gender

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* 4. Height

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* 5. Weight

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* 6. Physician contact information

Physician

Phone Number

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* 7. What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?

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* 8. How many days per week do you get at least 60 minutes of moderate-intensity exercise?

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* 9. Rank the importance of each goal to you.


Weight Loss	Weight Loss	Weight Loss	Weight Loss	Weight Loss	Weight Loss
Muscle gain	Muscle gain	Muscle gain	Muscle gain	Muscle gain	Muscle gain
Sports Performance	Sports Performance	Sports Performance	Sports Performance	Sports Performance	Sports Performance
Health Improvement	Health Improvement	Health Improvement	Health Improvement	Health Improvement	Health Improvement

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* 10. On a scale of 0 to 10, do you consider your overall diet to be healthy?

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 11. Are you currently following any kind of diet? If so, what diet and for what reason(s)?

Yes

If yes, for what reasons?

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* 12. How would you rank your daily salt intake: low, medium, or high?

Low

Medium

High

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* 13. How would you rank your daily sugar intake: low, medium, or high?

Low

Medium

High

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* 14. How would you rank your daily fat intake: low, medium, or high?

Low

Medium

High

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* 15. On a scale of 0 to 10, how effectively are you able to control your temptations for junk food?

0 No control

10 Complete control

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 16. How many alcoholic drinks do you consume per week?

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* 17. How many caffeinated beverages do you consume per week?

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* 18. Do you feel like you get enough sleep and wake up feeling rested each day?

Always

Usually

Sometimes

Rarely

Never

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* 19. On a scale of 0 to 10, how would you rate your average level of stress?

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 20. What techniques do you currently use to manage your stress levels?

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* 21. Do you smoke tobacco or use a vaporizer alternative?

Yes

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* 22. What is your occupation?

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* 23. Does your occupation require extended periods of sitting? (If YES, please explain.)

Yes

Please explain if yes.

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* 24. Does your occupation require repetitive movements? (If YES, please explain.)

Yes

If yes, please explain.

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* 25. Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?

Yes

If yes, please explain.

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* 26. Does your occupation cause you anxiety or mental stress?

Yes

If yes, please explain.

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* 27. Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.)

Yes

If yes, please explain.

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* 28. Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please explain.)

Yes

If yes, please explain.

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* 29. Please list out any past musculoskeletal injuries:

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* 30. Please list out any past surgeries:

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* 31. If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance
from a doctor to return to physical activity?

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* 32. Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary
disorders, hypertension, diabetes, or cancer)? (If YES, please explain.)

APP Personal Training Lifestyle Questionnaire

Personal Information

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* 1. Client Information

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* 2. Age

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* 3. Gender

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* 4. Height

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* 5. Weight

Question Title

* 6. Physician contact information

Question Title

* 7. What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?

Question Title

* 8. How many days per week do you get at least 60 minutes of moderate-intensity exercise?

Question Title

* 9. Rank the importance of each goal to you.

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* 10. On a scale of 0 to 10, do you consider your overall diet to be healthy?

Question Title

* 11. Are you currently following any kind of diet? If so, what diet and for what reason(s)?

Question Title

* 12. How would you rank your daily salt intake: low, medium, or high?

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* 13. How would you rank your daily sugar intake: low, medium, or high?

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* 14. How would you rank your daily fat intake: low, medium, or high?

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* 15. On a scale of 0 to 10, how effectively are you able to control your temptations for junk food?

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* 16. How many alcoholic drinks do you consume per week?

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* 17. How many caffeinated beverages do you consume per week?

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* 18. Do you feel like you get enough sleep and wake up feeling rested each day?

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* 19. On a scale of 0 to 10, how would you rate your average level of stress?

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* 20. What techniques do you currently use to manage your stress levels?

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* 21. Do you smoke tobacco or use a vaporizer alternative?

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* 22. What is your occupation?

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* 23. Does your occupation require extended periods of sitting? (If YES, please explain.)

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* 24. Does your occupation require repetitive movements? (If YES, please explain.)

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* 25. Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?

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* 26. Does your occupation cause you anxiety or mental stress?

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* 27. Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.)

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* 28. Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please explain.)

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* 29. Please list out any past musculoskeletal injuries:

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* 30. Please list out any past surgeries:

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* 31. If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearancefrom a doctor to return to physical activity?

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* 32. Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonarydisorders, hypertension, diabetes, or cancer)? (If YES, please explain.)

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* 33. Are you on any medications, and if so, have you received clearance from your doctor to take part in physicalactivity?

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* 34. Is there anything else you would like us to know?

* 31. If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance
from a doctor to return to physical activity?

* 32. Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary
disorders, hypertension, diabetes, or cancer)? (If YES, please explain.)

* 33. Are you on any medications, and if so, have you received clearance from your doctor to take part in physical
activity?