Screening Questionnaire

Name & Surname
ID Number
Email Address
Cell Number
Birthday

Complete the following questions to receive a customised wellness recommendation

Current Weight
How serious are you?
Height
Goal Dress/Pants Size
Goal Weight
BMI
Current Dress/Pants Size
BP
Age
Other Nutrition Programs Tried
Why didn't these Programs work for you?
Why do you want Change Now/ Gain muscle? Fat loss? Healthy lifestvle?
Times per week you eat out

EATING & LIFESTYLE HABITS

What time do you wake up?
Do You Wake Up Tired?
Do you lose energy during the day?
What do you Eat & Drink for Breakfast?
What is your Mid-Morning Snack?
What do you generally eat for Lunch?
What is your Mid-Afternoon snack?
What do you generally have for Dinner?
Do you have an Evening snack?
How many Cups of coffee / tea do you drink per day?
Glasses of Water Daily?
Do you suffer with lower back pain?
Have you ever had bypass surgery?
Sugar
Do you suffer with headaches?
Have you suffered from high blood pressure?
Smoke (How many per day?)
Do you suffer with constipation?
Have you suffered from a stroke?
How often do you drink alcohol?
How often do you eat chips/chocolate?
How often do you drink soft drinks?
Do you have any Health problems or concerns - If So, Please List
How many hours do you sleep?
Your occupation?
Do you do any form of Exercise & what?
How many times per week do you exercise?
Are you taking supplements, if YES please specify
Are you pregnant?
Do you take a multivitamin?
Training Commitment
Short term goals
Long term goals

Please read the 7 questions below carefully and answer each one honestly: check YES or NO

1. Has your doctor ever said that you have a heart condition OR high blood pressure?
2. Do you feel pain in your chest at rest, during your daily activities of living OR when you do physical activity?
3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
4. Have you ever been diagnosed with another chronic medical condition (other than heart disease or heart blood pressure)? :
Please list condition(s) here
5. Are you currently taking prescribed medications for a chronic medical condition?
Please list condition(s) and medications here
6. Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?
Please answer NO if you a problem in the past, but it does not limit your current ability to be physically active.
Please list condition(s) here
7. Has your doctor ever said that you should only do medically supervised physical activity?
Submit