Informational Servey | Chris Waters Fitness

Name *

Email address *

Phone Number *

Preferred Method of Contact *

Email
Phone

Have you ever had any pain or injuries? *

Have you ever had any surgeries? *

Has a medical doctor ever diagnosed you with a chronic disease such as, heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? *

Are you currently taking any medication? *

Please provide any other relevant medical information below. *

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes
No

Do you get any sort of chest pain when performing physical activity? *

Yes
No

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes
No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes
No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes
No

Do you know of any other reason why you should not engage in physical activity? *

Yes
No

*****LIFESTYLE AND GOAL QUESTIONS***** How many hours on average do you sleep every night? *

What time do you usually wake up in the morning? *

What are your first thoughts when you wake up? *

What is the first thing you do when you wake up? *

How do you normally breathe? *

What is your posture like while walking, standing, and sitting? *

How much water on average do you drink every day? *

How many meals on average do you eat every day? *

What is today's date? *

What is your age? *

What is your height, weight, and waist measurement (naval level)? *

Do you track your food intake? *

Yes
No

Do you have any food allergies, food intolerance, or dietary restrictions? *

Do you have any particular food preferences? *

When (what time) do you usually train in the day? *

Morning
Afternoon
Evening

What is your training/sports background (if any)? *

When was the last time you trained/were on a training plan? *

What is your current training protocol (if any)? *

Where do you exercise (location)? *

Gym
Home
Out Doors

Do you have any restrictions when it comes to training (physical, mental, etc.)? *

How do you feel during the day? *

Are your weekends different than your weekdays (sleep, activities, nutrition, self-talk)? *

We are what we do most of the time. Who are you based on the information you provided about your daily rituals? What is your self-image? *

Who do you want to be physically? *

When it comes to your physical state, what skills would you like to acquire/possess? *

What is your ideal physique (Skinny, slim, athletic, fit, muscular, etc.)? *

How many days per week would you like to train? *

When would you like to train? *

Where would you like to train (your location, outdoors, our location, live virtual)? *

ADDITIONAL NOTES: Please share any additional information or requests you have. *

Please fill out our questionnaire and we will be in contact with you shortly.