Fitness Profile

Health Questionaire
Let's begin to learn more about your health.
Name*
Email Address*
Please tell me what are the reasons and interests you have contacted EXtreme Personal Fitness.*

Personal Fitness TrainingWeight Loss/Fitness CoachingCustomized Fitness PlanNutritional GuidanceDiet and Meal/Eating PlansMy Book "28 Days to EXtreme Fat Loss"Hypnosis & HypnotherapyMotivation and EncouragementAccountability and Determination
Have you felt depressed over the last 6 months?

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Do you feel depressed about your weight or current body size/shape?

Type option 1Type option 2Type option 3Type option 4
How much sleep do you typically get at night?

8-9 hours7-8 hours5-6 hours4-5 hours3-4 hoursless than 3 hours
Do you have trouble sleeping at night?

I usually doSometimes I doI usually sleep soundly
Health & Diet
High Blood Pressure**

YesNo
Heart Disease**

YesNo
Diabetes/ Hypoglycemia**

YesNo
Arthritis/ Back Problems*

YesNo
Severity of Back Problems/Injury*

Previous Problem or InjuryCurrent Problem or InjuryMy back doesn't hurt that oftenMy back is always hurtingMy back feels greatMy back feels horribleMy back feels decentI have general basic back soreness/stiffnessI have major back problemsI go to massage therapy regularlyI see a Chiropractor regularlyI have had major back surgeryI have had a major back injuryI have no back back problems
Are you a cigarette smoker?*

YesNo
How many do you smoke a day?*
When do you smoke?*

DailyWeeklyAll the timeAfter mealsWhen stressedWhen drivingSociallyI am not a smoker
Do you drink alcohol?*

YesNo
When do you drink?*

Daily (every day)Weekly (every week)Regularly (a few times a week)SociallyWeekendsRarelyI don't drink alcohol
Do you have problems snacking or excessive eating/binging?*

Yes all the timeNo never at allYes sometimesNo hardly ever
Check all of those that have been problems for you.*

Excessive snackingExcessive eating/bingingEating only once a dayEating late at nightEating when stressedEating at restaurants more than twice a weekEating at restaurants once a day or moreNot eating breakfastCandy and SweetsDrinking 0 - 1 soda pop a dayDrinking 1 - 2 soda pops a dayDrinking 2 - 4 soda pops a dayDrinking 4 or more soda pops a dayNot drinking enough water daily
How many actual meals do you currently eat a day?*
How many snacks do you currently eat a day?*
Now adding up your actual meals plus your snacks, together how many times do you currently eat a day?*
How many eight ounce glasses of water do you drink daily?*
Exercise History
Have you ever exercised before?*

YesNo
Do you enjoy exercise?*

YesNo
Have you currently been exercising and working out regularly over the last 3 months? (12 weeks)*

YesNo
Have you currently been exercising and working out regularly over the last 3 months? (12 weeks)*

Yes both weight training and intense cardioYes both weight training and moderate cardioYes both weight training and basic cardioI have only been weight trainingI have been doing only intense cardioI have only been doing moderate cardioI have only been doing basic cardioI have not been weight training or doing cardio
How often have you done cardiovascular exercise over the last 3 or 4 months? (12 to 16 weeks)*

0 to 1 days a week1 to 2 days a week2 to 3 days a week3 to 4 days a week4 to 5 days a week5 to 6 days a week6 to 7 days a week
How often have you done actual weight training over the last 3 or 4 months? (12 to 16 weeks)*

0 to 1 days a week1 to 2 days a week2 to 3 days a week3 to 4 days a week4 to 5 days a week5 to 6 days a week6 to 7 days a week
Have you had any problems with either of these?*

Making time to exercise/weight trainProcrastinating getting started with exercise or working outStaying consistent with your exercise or workouts
Have you ever weight trained (lifted weights) before?*

YesNo
What kind of weight training or resistance training have you done?*

Nautilus EquipmentFree WeightsBasic Weight TrainingPower LiftingSuper SetsCross FitPyramid TrainingBody Sculpting ClassCircuit TrainingWeight Training at HomeBodyweight Exercises (push ups, pull ups, lunges, etc.)Other
Do you have any of the following patterns? Please check all that apply.*

I have gone on and off and on and off diets before many times.I have patterns of starting and stopping exercising.I have patterns of starting and stopping weight training.I have patterns of starting and stopping eating healthy.I have patterns of starting and stopping weight loss programs.I don't like drinking water and I don't drink enough of it.I am not consistent in taking vitamins & nutritional supplements.I don't have any of these patterns.
Please rate what you honestly perceive to be your overall stress level over the last 6 months.

10 High (Very High)9 High (Very High)8 High7 Medium (Medium - High)6 Medium - Normal5 Medium - Normal4 Medium - Low3 Low2 Low (Very Low)1 Low (Very Low)
Dedication & Motivation
Please acknowledge that you have completely read the above pricing structure where it says "Please Read Closely".*

Yes I have completely read the above pricing structure. If I have any questions regarding it, I will ask you during our first phone conversation.
Which best describes your current lifestyle?*

I have been saving up money and budgeting for this program over the last few months.I haven't been saving up money but I can easily put this program into my budget.I will start budgeting and saving up money immediately to start this program now.I will start budgeting and saving up money to begin this program within a few weeks.
How long have you been waiting for this right moment to get started on your fitness/weight loss goals?*

3 months6 months1 year2 years3 years5 years or more
How long has it been since you have weight trained?

3 months6 months1 year2 years3 years5 years or moreI am currently weight trainingI have never weight trained before
What has inspired you to contact me and start a fitness/weight loss program with me?*

Upcoming event (wedding, vacation, birthday)Desire to look better for datingYou are uncomfortable with clothes size/body sizeYou are tired of being/feeling tired (low energy)Doctor prescribed & recommended (health issues)Reduce stress & improve quality of lifeYou have not been seeing resultsYou need more motivationYou haven't been consistent with your workoutsNot sure what to do
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?*

You do like it and enjoy itYou really look forward to itYou are confused about what to doYou honestly dread it but know you need to do itYou are not sure if you can achieve your goalsYou feel very comfortable with itYou feel you can reach your goalsYou have been uncomfortable with itYou know you need help
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?*

You need more MOTIVATION.You are not sure what to do by yourself.You need better results than what you have been getting.You have not been achieving your goals.You need more energy.You need more support and encouragement.You need more self confidence & self esteem.You are not happy with your current body weight and/or body fat.You desire to look better and feel better.
What are your GOALS? *

Lose weight and burn fatFirm and toneGain weight (muscle)Increase energyDecrease stress levelsImprove cardiovascular healthIncrease enduranceSleep betterFeel better about yourselfImprove overall healthOther
Please tell me exactly what your weight loss or fitness goals or health goals are.*
How soon would you like to achieve your fitness/weight loss goals?*

3 - 6 months6 - 12 months12 to 18 months18 to 24 months24 months or longer
What are the biggest challenges that have stood in your way from achieving your goals?*

You are unsure about what to do in your exercise program.You need more MOTIVATION.Trying to find ways to fit it into your schedule.You need more patience to stick with the program long term.Emotional support (from family and friends)Your Diet & Eating PlanProcrastinationConvenience (having kids)Convenience (gym too far away)Sacrifice & DisciplineStaying CONSISTENT with your workoutsOther
Why is it important for you to achieve your goals NOW?*
What will your life be like 3 to 6 months from now if you don't take advantage of this opportunity to achieve your goals?*
If you have any comments please feel completely free to leave them here.
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!
Enter the message as it's shown*
BMI question?

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Do you feel tired often? Do you feel like you need more energy?

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How many 8 ounce glasses of water do you drink daily on average?

12-1610-128-10less than 8
How many grams of fiber do you eat daily on average?

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How many times a week do you eat out at restaurants?

12-1410-128-106-84-63-41-20
How many servings of fruits and vegetables do you typically eat daily?

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How often were you sick over the last year?

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How do you see yourself when you look in the mirror?

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Are you comfortable with how your clothes fit?

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Are you comfortable with your body size/shape?

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Have you ever felt constipated?

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How many bowel movements do you typically have per day?

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How many bowel movements do you typically have per week?

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