Lifestyle Questionnaire

Your Name

FirstLast

Birthdate

Home Address

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code

Country

Email Address

HomePhone

Cell Phone

Work Phone

What is your height?

What is your current weight?

Exercise Related Questions

If your exercise is less often than you'd like, what are the reasons?

What type of activities are you presently engaged in?

What type of exercise do you enjoy? Please list as many as possible.

Fitness Related Questions

When were you in the best shape of your life?

Have you been exercising for the last 3 months?

Yes
No

On a scale of 1-10 (1 worst, 10 best), how would you rate your current fitness condition?

Do you have any physical limitations? If yes, please explain here.

Nutrition Related Questions

On a scale of 1-10 (1 worst, 10 best), how would you rate your current nutrition?

How many times a day do you eat?

1-2 times per day
3-4 times per day
5-6 times per day
Other

Do you skip meals?

Yes
No

Do you eat breakfast?

Yes
No
Sometimes

Do you eat late at night?

Yes
No
Sometimes

What activities do you engage in while eating?

(examples: watching TV, driving, etc.)

Do you know how many calories you consume per day?

Yes
No

Do you take a multivitamin?

Yes
No

Besides hunger, why do you eat?

Please check all that apply.

Do you eat past the point of fullness?

Yes
No
Sometimes

On average, how many glasses of water do you drink per day?

Please list THREE areas of nutrition you'd like to improve.

Lifestyle Related Questions

Do you smoke?

Yes
No

How many alcoholic beverages do you have per week?

Describe your job:

Sedentary
Somewhat active
Active
Physical labor

Is anyone in your family overweight?

Please check all that apply.

Is anyone in your family overweight?

Please check all that apply.

Were you overweight as a child?

Yes
No

Please list your top 3 sources of stress.

On a scale of 1-10 (1 least, 10 most) how would you rate your current level of stress?

Goal Setting Related Questions

How can Angie best help you?

Please check all that apply.

Please list 3 fitness goals that you hope to achieve in the next 3-6 months.

Please list any obstacles that would change or slow your fitness goal progress.

Lifestyle Questionnaire

Exercise Related Questions

Fitness Related Questions

Nutrition Related Questions

Lifestyle Related Questions

Goal Setting Related Questions

Other Questions