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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