Doerz Fitness Assessment

1
How did you hear about us?
Facebook
Instagram
Referral
Google
Website
Other
2
Have you ever worked out with a Personal Trainer? * This field is required.
YESNO
3
Your Full Name* This field is required.
First Name
Last Name
4
Phone Number* This field is required.
Area Code
Phone Number
5
Gender
Male
Female
Decline to Answer
Other
6
Email* This field is required.
example@example.com
7
Birthday
Date
Year
Month
Day
8
Height* This field is required.
Feet & Inhes
9
Weight* This field is required.Approximate if exact weight is unknown
Lbs
10
On a scale of 1 to 10 what is your fitness level (10 being the fittest)* This field is required.
11
If you have any diagnosed health problems list the condition (high blood pressure, type 2 diabetes etc)
12
Do you currently have an injury, a movement limitation, or pain that limits your ability to exercise? (Knees, Back etc)
13
Are you taking any medications or drugs? If yes, please list medication, dose, and reason.
14
What are your primary fitness goals?* This field is required.
Reduce body-fat & weight loss
Improve cardiovascular fitness
Reshape or tone body
Strengthen body
Build muscle
Improve sport specific performance
Increase energy level
Improve flexibility and mobility
Improve self-confidence
Feel better, positive attitude
Maintain my workout consistency
Exercise safely and with proper form
Other
15
How many times a week can you commit to training?* This field is required.Type a number
16
Which habit is currently holding you back the most?
Overeating
Emotional eating
Lack of consistency
Not enough movement
Weekend eating
Lack of accountability
Stress
Sugary drinks
Poor sleep
Other
17
Give us 2-3 body parts you specifically want to focus on?
18
Does your significant other or a close friend/family member support your efforts in achieving your personal fitness goals? Skip if this does not apply
YESNO
19
How many hours of sleep do you get on average?
20
Does your occupation require much activity (i.e. walking, getting up and down, carrying things)?
21
What are the things that we can help you out with in order to make sure that you are successful?
Accountability
Nutrition accountability
Structure
Challenge
Variety
Other
22
How many meals are you eating daily?
1
2
3
4
5
23
How many times per day are you currently eating out?
1
2
3
4
None
24
What is that food or drink you can’t say NO to even on your best eating weeks?
25
Do you have any food allergies, sensitivities, or preferences?
26
On a scale of 1 to 10 (10 being the most serious) How serious are you about accomplishing your fitness goals?* This field is required.
27
When you look at your body, how closely do you think what you see matches how other people see you?
Very closely
Mostly closely
I’m not sure
I tend to see more flaws than others seem to notice
I’m extremely critical of my appearance
28
When you miss a workout or eat something you consider bad, what is your typical reaction?
I move on without much thought
I’m disappointed but recover quickly
I feel guilty or ashamed
I feel like I’ve failed or sometimes give up completely
I try to compensate by exercising more or restricting food
Should be Empty: