Trial Client Interview- Improvement Warrior Fitness- What Do You Want To Improve Initial Assessment
What is your first and last name?
Your answer
Improvement warrior fitness
What is your email address?
Your answer
Best Phone Number?
Your answer
What is your Height (Feet)?
Height (Inches)
What is your weight (pounds)
Your answer
What is your age?
Your answer
Do you know your body fat percentage?
Your answer
Are there any injuries or limitations in regards to exercise/movement?
Your answer
What specific areas are you MOST interested in? (Select all that apply)
Tell us a little bit more about your goals and what you'd like to achieve with us
Your answer
Why do you want to acheive that?
Please get as deep as you can. Remember this is YOUR life and you need to have a BIG enough reason to change otherwise it won't happen for you.
Your answer
Dietary Section
How would rate your current nutrition intake?
Please use a scale of A+ to F just like school
Your answer
Please write out a typical day’s worth of food and liquid intake (a day that gives us a good idea of your overall nutrition. Please include times and amounts if known?
Example: 1. Breakfast 600 am ___________ 2. Mid Morning Snack 1000am _____________ 3. Lunch etc.........
Your answer
What’s your biggest weakness/challenge in regards to nutrition?
Your answer
How much water do you drink on average?
In ounces or cups please
Your answer
Do you drink tap water?
Your answer
How many servings of Vegetables do you eat on average a day?
Your answer
Are you taking any supplements?
Please list brands and type if known. And reason for taking it
Your answer
Any medications/prescriptions? Please list what they are treating---
This includes over-the-counter. If not comfortable putting please indicate # of medications.
Your answer
Do you know how many calories you are eating per day on average?
Your answer
Do you know how many grams of carbohydrates you eat per day?
Your answer
Do you know how many grams of fat you eat per day?
Your answer
How often do you use artifical sweeteners or use products that contain them?
Sweet N Low, Equal, Splenda, Sucralose, or Nutrasweet, etc......
How often do you eat fast food like McDonald's, Burger King, Taco Bell?
Health Section
How would you describe your current overall health?
Your answer
What has contributed most with your past unsuccessful attempts to control your nutrition, health, weight, etc.....
Please be as detailed as possible
Your answer
How many hours a day would you say you SIT on average?
Include work, school, eating, driving, waiting, etc.........
Your answer
How many hours do you sleep on average on WEEKNIGHTS
How many hours of sleep on WEEKENDS
What time do you usually go to bed on weeknights? Weekends?
Should be 2 answers unless it is same for both
Your answer
When you wake up, how do you feel?
Your answer
On a scale of 1 to 10 how much stress would say you have at your work?
10 is highest
On a scale of 1 to 10 how much stress would say you have at your home?
10 is highest
Do you know if you have any of the following?
Ready to get started
Our class schedule is below. Which class(es) would you be attending?
R= Thursday | Hilliard- 4601 Leap Ct, 43026
Which Trial would you most likely be starting with us with?
Please see comparison below. Groupons and Daily deals and gift certificates would fall in the 2-week category.
When you you like to start? Date?
MM
/
DD
What is your address?
Only fill this out if you are registering for a trial.
Your answer
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