Initial Questionnaire
Welcome to the beginning of your journey with Delta Performance.

To start this process, we ask that you take some time to fill out this intake questionnaire. This is a very important step in your journey as it will guide us on how to best coach you toward your goals.

Below, there are a number of questions about your lifestyle, goals, and beginning measurements.

Please give yourself enough time to answer these questions with as much DEEtail as possible. The more we know about you, the better we can tailor this service to your needs.
Email address *
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Phone Number *
Your answer
Address *
street, city, state, zipcode
Your answer
Height and Weight
Your height and weight will be used as a baseline to help us build a fitness and nutrition plan best for you.
What is your height in inches?
Your answer
What is your weight in pounds?
Your answer
Motivation / Goals
What is motivating you to take this step in your life? What are your specific goals?
What would you say is your biggest motivator(s) to hiring a fitness / nutrition coach? *
Required
What are your specific athletic / fitness goals? (i.e. complete first 5-K, deadlift 300 pounds, be able to complete a push up unasissted etc.) The more specific, the better. *
Your answer
What other specific goals do you have? (i.e. lose 20lbs by July, improve my daily energy to play with my kids, etc.) Again, the more specific, the better. *
Your answer
Why are these goals important to you? *
Your answer
Right now, how much do the people and things around you support your health, fitness, and/or behavior change goals? *
No support
Best support system ever
Expectations
Just as your coaches have certain expectations of you, we are sure you have specific expectations of your coaches.
What are you expecting to receive from your Delta Performance coach? *
Your answer
What are you prepared to do to work towards your goals? *
Your answer
Nutrition Baseline
Please answer each question honestly and openly. We are not here to judge you, and you should not judge yourself either. You answers will help us develop the most realistic plan for where you are right now.
How would you rank your overall nutrition habits right now?
Worst nutrition choices ever
Best nutrition choices
On average, what does your current nutrition intake look like? (If possible, include total calories, carbs, protein and fats.) *
Your answer
Do you have any allergies, intolerance, or dietary preferences?
Your answer
How many alcoholic beverages do you drink per week? (liquor: 1serving = 1.5oz; beer: 1serving = 12oz; wine: 1 serving = 5oz)
Your answer
How many cigarettes / cigars do you smoke a day / week on average? *
Your answer
What do you think are your biggest struggles with nutrition? Currently or in the past.
Your answer
Do you use any supplements? (if so, please list supplement and dose) *
Your answer
Movement Baseline
These questions dig into your current activity level.
When you exercise on your own or at another gym, what does a typical workout/training session look like? (Be as specific as possible.) *
Your answer
In the last 7 days, how many times did you exercise? (This is intentional movement geared toward your fitness goal). *
Your answer
How many days can you commit to moving 30 minutes or more in any given week? *
Your answer
Typical Day
We can only be with you 1-4 hours of your 168 hour week. What you do outside of training here matters. Please be specific in enlightening us with what a typical week looks like for you.
What does a typical weekday day look like? From wake to sleep, what does your schedule look like? *
(i.e. What do you do for a living? What does that entail (specifically with movement and stress level)? How often are you restaurant eating, meal prepping, sleeping, on your feet, etc.)
Your answer
What does a typical weekend day look like? *
Your answer
How would you rank your schedule and overall "busy-ness?"
I don't even have time to pee
I have all the time in the world.
Medical History
Please be specific and honest when answering these questions. Medical history plays heavily in developing a nutrition/fitness plan for you. Please know all these answers are completely confidential, and we are not here to judge but to help. The more information you give us, the better we can help you.
How would you rank your health right now? *
Worst Health
Best Health
Given all the demands in your life, what is your typical stress level on an average day?
I have no stress
My life is extremely stressful
How do you normally cope with stress? *
Your answer
In the last seven days, how many hours of sleep did you average per night? *
What is your current pain level? *
No pain
Most pain I've ever felt
Do you or have you ever suffered from any medical illnesses? *
(if so, please specify date, treatment plan, medication, and if you are still on treatment)
Your answer
Do you or have you ever suffered from any injuries? *
(if so, please specify date, treatment plan, medication, and if you are still on treatment)
Your answer
Do you or have you ever suffered from any type of eating disorder? *
(If so, what was the treatment and are you still undergoing treatment for it? When was the last episode?)
Your answer
Are you pregnant? Or have you been pregnant in the past six months? *
Are you currently breastfeeding? Or have you been breastfeeding in the past six months? *
Who is your primary care physician? (name and phone number) *
Your answer
May we contact your PCP regarding any concerns / questions we may have in your health? *
Ready, Willing, and Able
How important is it for you to meet your goals? *
Not important at all
Most important thing in my life
How confident are you that you can meet your goals? *
No confidence at all
Extremely confident
Where does meeting your goals land on your priority list? *
This is my last priority
This is my top priority over everything else in my life.
Are you ready, willing, and able to dedicate at least 30 minutes a day to achieve your goal? *
Who may we thank?
Why did you choose to reach out to Delta Performance? *
Required
If you were referred, who may we send a bear hug to?
Your answer
Disclaimers
Whoa! That was a lot. We appreciate your time while filling out this application. Bare with us as this is the last section.
Medical Release
Every individual who has consistently attended and completed our coaching program has become healthier and /or more fit. That being said, we still need to be sure you take full responsibility for your health and the monitoring of it.

It's important that you understand:

1) Our coaching cannot and does not replace the advice of your trained medical professional.

2) It is your responsibility to work directly with your physician before, during, and after becoming a nutrition athlete at Delta Performance

3) If you choose to be coached by us without the prior consent of your physician, you agree to accept full responsibility for your decisions and to hold harmless Delta Performance, its coaches, officers, and employers and any affiliated companies from any liability with respect to injury to you or your property arising out of or connected with your use of the coaching and information provided.
Please type you initials to indicate that you understand and consent to this medical release *
Your answer
Privacy Policy
Your privacy is very important to us. Please copy and paste this link, read our privacy policy, and ensure you understand everything in the content prior to submitting this form.

https://drive.google.com/open?id=1D3a0rd2WgrwGxnVeMCld6bQ4c7a5XCSe
Please type your initials when you have read, understand, and consent to Delta Performance's Privacy Policy *
Your answer
Terms, Conditions, and Agreement
Please copy and paste this link, read our terms, conditions, and agreement, and ensure you understand everything in the content prior to submitting this form.

https://drive.google.com/open?id=1IHmi-2zj0AsefWSGzljT4__7Tbolc6u8
Please type your initials when you have read, understand, and consent to Delta Performance's Terms, Conditions, and Agreement *
Your answer
Thank you
The information you provided us with will help us build a plan just for you. Your coach is currently reviewing this information and building a plan for you. Hang tight. We will contact you soon.
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