Surveypoint

Q1

Full Name:*

Q2

Email address*

Q3

Address:*

Q4

Contact Number:*

Q5

Date of Birth

Month

Q6

Date of Birth

Day

Q7

Date of Birth

Year

Q8

Age:*

Q9

Emergency Contact Person & Contact Number*

Q10

Marital Status

Q11

Kids

Q12

How much alcohol do you consume weekly?

Q13

On average how much sleep do you get a night?

Q14

Have you recently had a medical check up?*

Q15

Are you currently on any medication? If yes, what is it and what is it for?*

Q16

If yes what is it & what is it for?

Q17

Are you currently pregnant or recently given birth?*

Q18

Are you a smoker or ever smoked?

Q19

Have you ever had surgery *

Q20

If yes, when and what for?

Q21

Do you have any physical conditions or movement restrictions that may affect your training?*

Q22

If yes, please give details

Q23

Are you currently exercising?*

Q24

If yes, what are you doing?

Q25

Are you seeing a physician or health professional? *

Q26

If yes, what for and who are you seeing

Q27

Have you been advised by a health professional to undertake an exercise program?*

Q28

Have you been advised by a health professional to AVOID or INCLUDE any particular exercise?*

Q29

If yes, please explain in more detail

Q30

Do you have any of the following MEDICAL CONDITIONS?*

Q31

Other than previously stated, Is there anything else you can think of that may affect your training in any way?

Q32

List your experience with exercise over the past 5 yrs?*

Q33

Have you had a PT before?*

Q34

If yes, did you get the results you wanted?

Q35

How would you rate your experience with PT

Q36

What is your number 1 reason for contacting us?*

Q37

Based on your selection above, please give a short description of what you believe your selection is and entails*

Q38

If i asked you to look at yourself in the mirror right now, what do you see?

Q39

What is the time frame for achieving these goals? Is there something important coming up eg: birthday, anniversary etc

Q40

On a scale of 1-10 how important is reaching your goal to you? *

Q41

What do you think will be your biggest obstacles when reaching your goals?

Q42

If other, please give a short description

Q43

What do you want the most from these sessions?*

Q44

Do you have a weekly budget you are willing to invest in helping you achieve these goals?

Q45

Do you need help with nutrition?

Q46

List what you typically eat for breakfast?

Q47

List what you typically have for dinner?

Q48

List what you typically eat for lunch?

Q49

List what you typically snack on between meals?

Q50

Strength Empire Consult Form -Form Fill

Full Name:*

Email address*

Address:*

Contact Number:*

Date of Birth

Date of Birth

Date of Birth

Age:*

Emergency Contact Person & Contact Number*

Marital Status

Kids

How much alcohol do you consume weekly?

On average how much sleep do you get a night?

Have you recently had a medical check up?*

Are you currently on any medication? If yes, what is it and what is it for?*

If yes what is it & what is it for?

Are you currently pregnant or recently given birth?*

Are you a smoker or ever smoked?

Have you ever had surgery *

If yes, when and what for?

Do you have any physical conditions or movement restrictions that may affect your training?*

If yes, please give details

Are you currently exercising?*

If yes, what are you doing?

Are you seeing a physician or health professional? *

If yes, what for and who are you seeing

Have you been advised by a health professional to undertake an exercise program?*

Have you been advised by a health professional to AVOID or INCLUDE any particular exercise?*

If yes, please explain in more detail

Do you have any of the following MEDICAL CONDITIONS?*

Other than previously stated, Is there anything else you can think of that may affect your training in any way?

List your experience with exercise over the past 5 yrs?*

Have you had a PT before?*

If yes, did you get the results you wanted?

How would you rate your experience with PT

What is your number 1 reason for contacting us?*

Based on your selection above, please give a short description of what you believe your selection is and entails*

If i asked you to look at yourself in the mirror right now, what do you see?

What is the time frame for achieving these goals? Is there something important coming up eg: birthday, anniversary etc

On a scale of 1-10 how important is reaching your goal to you? *

What do you think will be your biggest obstacles when reaching your goals?

If other, please give a short description

What do you want the most from these sessions?*

Do you have a weekly budget you are willing to invest in helping you achieve these goals?

Do you need help with nutrition?

List what you typically eat for breakfast?

List what you typically have for dinner?

List what you typically eat for lunch?

List what you typically snack on between meals?

Please feel free to jot down anything else you think i may of forgotten that could benefit you & getting you to your goals quickly and safely