Initial Client Questionnaire

Name *
Name
Date *
Date
Date of Birth *
Date of Birth
In general, what are your goals? *
Please check all that apply.
How do you prefer me to contact you?
Please check all that apply.
Number concerns 1 (most) to 3.
If so, what?
(Even if you might not be doing it right now.)
1 = horrible, 10 = awesome
Are you regularly active in sports and/or exercise? *
If so, how many hours per week? *
Approximately how many hours per week do you do other types of physical activity? *
(e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
Who lives with you? *
Please check all that apply.
If yes, how many and what are their ages?
Who does most of the grocery shopping in your household? *
Please check all that apply.
Who does most of the cooking in your household? *
Please check all that apply.
Who decides on most of the menus/meal types in your household? *
1 = not at all, 10 = completely
Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? *
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries? *
Right now, are you taking any medications, either over-the-counter or prescription? *
1 = worst, 10 = awesome
In an average week, which do you spend time doing... *
Please check all that apply.
1 = my life is packed and insane, 10 = my life is perfectly calm and relaxed
1 = no stress, 10 = extreme stress
On average, how many hours per night do you sleep? *
1 = not at all, 10 = completely
1 = not at all, 10 = completely
1 = not at all, 10 = completely