M6 Client Physical Readiness Questionnaire (PRQ)
Name
*
First Name
Last Name
E-mail
*
Client Number:
*
Training & Excercise History
Have you belonged to a gym before?
*
Yes
No
Which one?
Have you used a personal trainer before?
*
Yes
No
Which one? What results did you get? What did you like, and what didn't you like?
Have you been a part of any boot camps, corporate wellness programs, etc?
*
Yes
No
If so, what worked and what didn't?
Are there or were there specific exercises or moves that caused you pain? Such as overhead lifts, squats, etc.
*
Yes
No
If so, what worked and what didn't?
*
Food Assessment:
Have you ever been to a nutritionist or dietician before?
*
Yes
No
If so, please provide additional info?
*
Tell us about any past dieting?
Approximately how many meals a day do you eat?
*
What do you typically eat for breakfast?
*
What do you typically eat for lunch?
*
What do you typically eat for dinner?
*
What do you typically eat for snacks?
*
How much water do you typically drink daily?
*
Please indicate in ranges 0 - 12 oz, 12 - 24 oz, etc.
What types of other liquids do you drink daily?
*
If you drink sodas, how often and how much?
If you drink sports drinks, what kind, how often and how much?
Do you drink coffee?
*
Yes
No
How many cups a day?
What do you add?
Nothing
Cream
Sugar
Other stuff
Do you take supplements?
*
Yes
No
When?
Pre-Workout
Post-Workout
Another Time
List supplements you take, including any vitamins:
Do you consume alcohol?
*
Yes
No
How often?
Daily
A few times a week
A few times a month
A few times a year
Other
Demographic and Health Information:
Have you ever had back problems?
*
Yes
No
Describe your back problems and how they affect you:
Have you had any inner ear or balance issues?
*
Yes
No
Describe your inner ear or balance issues. Do they still affect you today?
Please list any past surgies you have had? Explain any lingering affects.
Do you have high blood pressure?
*
Yes
No
Are you on any medication for HBP?
Yes
No
Please list any medications you are currently taking that we should be aware of:
*
Do you have, or have you had, any heart issues or conditions?
*
Yes
No
Please describe:
Do you have any food allergies?
*
Yes
No
List your food allergies here:
Please tell us about any normal aches, pains and physical issues you experience on a regular basis:
*
Please list any other known conditions that we should be aware of:
Sleep Habits
On average how many hours do you sleep nightly?
*
How would you rate your quality of sleep?
*
Awesome!
Good
Not Bad
OK
No Good
Really Bad
How do you feel when you wake up in the mornings?
*
Fully rested every day
Fully rested most days
Fully rested on occassion
Tired most days
Tired every day
Do you tend to fade in the afternoons, and/or feel like you need a nap?
*
Yes
No
Sometimes
Do you feel like you need caffeine to get going daily?
*
Yes
No
Sometimes
Do you need anything or take anything to help you sleep?
*
Yes
No
Sometimes
Please describe anything you take to help you sleep? Alcohol, Supplements, etc.
Sports Participation History
What's the highest level of sports you have played?
*
Middle School
High School
Junior College
4 Year Non-D1
4 Year D1
Professional
Amateur
None
Please tell us about your sports history or your current sports
Other Information
Please provide any additional information you think we should know:
Enter the message as it's shown
*
Save
Submit
Clear Form
Print Form
Should be Empty: