Name *
Name
GOALS
EXERCISE
How would you rate your current fitness level?
Are you currently exercising regularly?
Have you ever tracked how many steps you take during the day?
Not including structured exercise, how active are you on a daily basis?
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?
NUTRITION
Do you have any known food allergies or intolerances?
Do you enjoy cooking?
MISCELLANEOUS
How old are you?
How would you rate your current stress levels?
On average how would you rate your sleep?
How would you like to measure progress? Tick all that apply
Getting fit or losing weight requires changing something about the way you currently eat or exercise. How motivated are you to make this happen?
LAST BUT NOT LEAST