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QUESTIONNAIRE FORM

ASSESSING YOUR NEEDS:
All information received on this form will be treated as strictly confidential. Wed on not sell, trade or expose your personal information. Please fill out the form as completely & accurately as possible. This information is essential to helping me develop a program that addresses your needs, goals & interests.

You will be automatically re-directed to the Release Form upon completing this form. Please be sure to fill the Release Form out as it is MANDATORY before any training session or fitness assessment can begin.

* REQUIRED FIELDS

 

 

Kinetix Questionnaire Form
First
Last
Are you Active Duty Military, Reserves or DoD? *
Have you or anyone you know tested positive COVID-19 within the last 14 days? *
Male / Female
Describe why you decided to invest in Personal Training? Select all that apply
Why did you decide to train with Kinetix? Check all that apply
Has your doctor ever said that you have a heart condition & recommended only medically supervised physical activity? *
Do you frequently have pains in your chest when you perform physical activity? *
Do you ever feel dizzy or light headed when doing physical activity? *
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program * (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respitory aliments, back problems, etc? *
Are you pregnant now or have been in the last 6 months?
Have you had any surgeries within the last three months? *
Do you smoke?
Do you drink alcohol more than twice per week?
Describe your job
Does your job require you to travel?
Is anyone in your family overweight?
Were you overweight as a child?
Have you been exercising in the past 3 months?
Do you have exercise equipment at home? *
If you answered yes above please check all that apply
Do you skip meals?
What type of foods do you prefer more often?
Do you eat late at night?
Do you eat breakfast?
Do you feel drops in your energy throughout the day?
If you answered yes to the previous answer, what part of the day would you say your energy levels drop?
Do you know how many calories you consume per day?
Are you or have you taken any multi-vitamin or any other sports supplement?
At work or school, do you usually:
Do you do your own grocery shopping?
Do you do your own cooking?
Besides hunger, what are other reasons you eat? Please check all that apply.
Do you eat foods that are high in fat and sugar?
How often are you willing to partake in physical exercise?
Are you currently training at any other gym facility? *
What are the best days of the week for you to commit to an exercise program? Check all that apply
What times throughout the day are best able to train? *
How committed are you to achieving your fitness goals?

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