Question Title

* 1. Name

Question Title

* 2. Address

Question Title

* 3. Telephone Number

Question Title

* 4. Email Address

Question Title

* 5. Preferred day/time for training?

Question Title

* 6. Do you have a preferred trainer or type of trainer?

Personal and Goal Questionnaire - to help design your perfect programme

Question Title

* 7. Do you have, or have every suffered from...

Question Title

* 8. Have any of your first-degree relatives experienced the following conditions?

Question Title

* 9. Have you ever had surgery?

Question Title

* 10. Have you ever broken any bones?

Question Title

* 11. Do you suffer from back pain?

Question Title

* 12. Do you have tension or soreness in a specific area?

Question Title

* 13. Do you experience numbness, tingling or stabbing pains anywhere? 

Question Title

* 14. Are you sensitive to touch/pressure in any area?

Question Title

* 15. Do you experience stiff, swollen or painful joints?

Question Title

* 16. What is your “chief complaint”?

Question Title

* 17. Treatment to date

Question Title

* 18. Are the symptoms brought on by certain activities?

Question Title

* 19. Do specific activities or positions alleviate your symptoms?

Question Title

* 20. When is the pain worse?

Question Title

* 21. Do you experience fatigue or lack of energy? If yes provide details.

Question Title

* 22. What is your current weight?

Question Title

* 23. Have you had any of the following: physical therapy, osteopathy, chiropractic, massage therapy, other? Please elaborate.

Question Title

* 24. Please list any medications you are currently taking.

Question Title

* 25. Occupation; please explain your position along with the physical and mental responsibilities involved.

Question Title

* 26. Do you have an ergonomically set up desk/workstation?

Question Title

* 27. How many hours do you spend in front of a computer?

Question Title

* 28. How much time do you spend in a seated position?

Question Title

* 29. On a scale of 1 to 10 (1=not active, 10=very active) please rate how active you are on a daily basis?

Question Title

* 30. Do you consider yourself to be under stress? If yes provide details.

Question Title

* 31. Are you currently involved in any exercise programme? If yes please list how long and what type of exercises.

Question Title

* 32. Have you ever had a personal trainer? If yes provide details of when and for how long?

Question Title

* 33. Do you smoke? Yes No If yes, how many per day

Question Title

* 34. Do you follow, or have you recently followed, any specific dietary intake plan, and in general how do you feel about your nutritional habits?

Question Title

* 35. Daily Dietary Intake

Question Title

* 36. Please list THREE goals in order of importance:

Question Title

* 37. How much time are you willing to devote toward achieving this goal?

Question Title

* 38. What is the biggest challenge you must overcome in attaining your goal?

Question Title

* 39. On a scale of 1 to 10 (1=not committed, 10=very committed), please rate how committed you are to achieving your goal?

Question Title

* 40. List three tasks you can do daily, which will help pave the path toward total achievement?

Question Title

* 41. All information on this form is correct to the best of my knowledge and I have sought, and followed,any necessary medical advice.

All information in this questionnaire is confidential and will be used to help design a programme that is personal to you.

Question Title

* 42. Is there anything else that you feel we should know?

Question Title

Image

T