• Health Questionaire  

  • Let's begin to learn more about your health.

  • Please tell me what are the reasons and interests you have contacted EXtreme Personal Fitness.*
  • Have you felt depressed over the last 6 months?
  • Do you feel depressed about your weight or current body size/shape?
  • How much sleep do you typically get at night?
  • Do you have trouble sleeping at night?

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    Health & Diet 

     

  • High Blood Pressure**
  • Heart Disease**
  • Diabetes/ Hypoglycemia**
  • Arthritis/ Back Problems*
  • Severity of Back Problems/Injury*
  • Are you a cigarette smoker?*
  • When do you smoke?*
  • Do you drink alcohol?*
  • When do you drink?*
  • Do you have problems snacking or excessive eating/binging?*
  • Check all of those that have been problems for you.*

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    Exercise History

     

  • Have you ever exercised before?*
  • Do you enjoy exercise?*
  • Have you currently been exercising and working out regularly over the last 3 months? (12 weeks)*
  • Have you currently been exercising and working out regularly over the last 3 months? (12 weeks)*
  • How often have you done cardiovascular exercise over the last 3 or 4 months? (12 to 16 weeks)*
  • How often have you done actual weight training over the last 3 or 4 months? (12 to 16 weeks)*
  • Have you had any problems with either of these?*
  • Have you ever weight trained (lifted weights) before?*
  • What kind of weight training or resistance training have you done?*
  • Do you have any of the following patterns? Please check all that apply.*
  • Please rate what you honestly perceive to be your overall stress level over the last 6 months.

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    Dedication & Motivation

     

  • Which best describes your current lifestyle?*
  • How long have you been waiting for this right moment to get started on your fitness/weight loss goals?*
  • How long has it been since you have weight trained?
  • What has inspired you to contact me and start a fitness/weight loss program with me?*

  • Having friends and famly join us is a really smart idea!  

    You save money this way and have more fun! 

    I do offer a discount when 2 or more people personal train with me at the same time during the same session.

    I also offer weight loss coaching for small groups!

  • What are your thoughts on exercise, weight training, and fitness?*
  • What are the REAL reasons why you are thinking/feeling that you need to start with a Personal Trainer and/or a Weight Loss/Fitness Coach?*
  • What are your GOALS? *
  • How soon would you like to achieve your fitness/weight loss goals?*
  • What are the biggest challenges that have stood in your way from achieving your goals?*

  • Thank you for your inquiry to EXtreme Personal Fitness!

    I will connect with you within usually 24 hours.

    Go EXtreme for LIFE!  EXtremeforLIFE.com

    Let's Start Your Program Today!

  • Reload
  • BMI question?
  • Do you feel tired often? Do you feel like you need more energy?
  • How many 8 ounce glasses of water do you drink daily on average?
  • How many grams of fiber do you eat daily on average?
  • How many times a week do you eat out at restaurants?
  • How many servings of fruits and vegetables do you typically eat daily?
  • How often were you sick over the last year?
  • How do you see yourself when you look in the mirror?
  • Are you comfortable with how your clothes fit?
  • Are you comfortable with your body size/shape?
  • Have you ever felt constipated?
  • How many bowel movements do you typically have per day?
  • How many bowel movements do you typically have per week?
  • Should be Empty: