Distance Training Questionnaire:



Top Form Fitness Client Questionnaire:

What is your birth date? __________________________________________________

What is your height? _____________________________________________________

What is your current body weight? __________________________________________

Please take the following Girth Measurements (using a flexible tape measure):

• Waist circumference at belly button ____________________________________

• Hips at widest circumference around glutes _____________________________

• Right Bicep flexed _________________________________________________

• Mid-thigh ________________________________________________________

• Chest circumference, relaxed ________________________________________

• *Body Fat % (*only if you have a way to measure it) ______________________

How many hours of sleep do you average each night? ___________________________

How long have you been weight training? (months, years): _______________________

What are your primary sports or physical activities? _____________________________

How many days per week do you currently weight train? _________________________

What is the maximum number of days you can exercise each week? _______________

What are your favorite exercises / lifts? _______________________________________

What is your least favorite exercise? _________________________________________

Do you have any injuries that are still affecting your physical activity? (ie: Lower back, knees, shoulders, etc). If so please list and describe:

______________________________________________________________________

______________________________________________________________________

What exercises / movements do you find challenging, uncomfortable or painful? List:

______________________________________________________________________

Can you correctly perform a full range overhead squat with an empty bar? ___________

How many strict, full range bodyweight chin-ups can you perform? _________________

How many strict, full range bodyweight parallel bar dips can you perform? ___________

Where do you usually train? (ie: fitness center, home gym, etc) ____________________

What equipment do you have available to you? ________________________________

______________________________________________________________________

What are your primary fitness / training goals? _________________________________

______________________________________________________________________

______________________________________________________________________

SAMPLE DAILY NUTRITION JOURNAL

|Meal/ Time |List All Food and Drink Consumed on an Average Day |

|Breakfast | |

| | |

|_____:_____ | |

|Snack | |

| | |

|_____:_____ | |

|Lunch | |

| | |

|_____:_____ | |

|Snack | |

| | |

|_____:_____ | |

|Dinner | |

| | |

|_____:_____ | |

|Snack | |

| | |

|_____:_____ | |

NOTES:

Current Physical Activity Routine

|Outline your current weekly training program, including all regular physical activities: |

|Monday | |

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|Tuesday | |

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|Wednesday | |

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|Thursday | |

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|Friday | |

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|Saturday | |

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|Sunday | |

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*Remember to email your training results to me each week!

Josh@Top-Form-

Nutrition & Lifestyle Questionnaire

1. How often do you shop for groceries? ________________________________

2. How often do you eat vegetables each day? ___________________________

3. How often do you eat fruits each day? ________________________________

4. Do you usually eat packaged (frozen/canned) OR fresh fruits and vegetables?

________________________________________________________________

5. Do you use a microwave oven? _____________________________________

6. How many cups or liters of water do you drink each day? _________________

7. How often do you drink pasteurized milk or eat cheeses? _________________

8. How many servings of high protein foods do you eat each day? ____________

9. What are your 4 favorite sources of protein? i) _________________________

ii) _______________ iii)_________________ iv) ___________________

10. What are your 4 favorite sources of carbohydrate? i)____________________

ii) _______________ iii) _________________ iv)___________________

11. How many meals / snacks do you eat each day? ______________________

12. What are your 3 favorite snacks? __________________________________

13. How often do you eat at fast food restaurants like McDonalds, Wendy’s, etc?

________________________________________________________________

14. Do you skip meals? _________ Do you often skip breakfast? ___________

15. Do you consume a source of Essential Fatty Acids (ie- Omega 3) on a daily basis? If so, what source (ie- fish oil, flax oil, etc) and how much?

________________________________________________________________

16. List the supplements you regularly take: _____________________________

________________________________________________________________

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