Health & Wellness Questionnaire Please take a moment to answer the questions below. All information is 100% confidential and will help us in programming/coaching to assist you in meeting your personal health and fitness goals! * = required field Name* Email* Date of Birth* Age* Gender* MaleFemale General Medical History 1. Do you have any Medical/Musculoskeletal Complaints? If Yes, please describe below. 2. Have you been Diagnosed by a Physician with ANY medical condition? If Yes please list below. 3. Do you take any prescription or over the counter medications? Please List. Exercise History 1. Do you participate in any form of regular exercise?YesNo a. What form of exercise? b. How many times per week? c. How long each sessions d. How intensely do you exercise? e. How long have you been regularly training? Health Goals 1. Please describe your major health, nutrition and/or fitness goals: 2. What do you see as the biggest barriers to achieving these goals? 3. What are the two greatest strengths that will help you achieve these goals? 4. On a scale of 1-10, how important is achieving these goals? 5. On a scale of 1-10, how confident are you that you will succeed? Nutrition History 1. Are you satisfied with your current Nutrition program? 2. Do you follow a specialized diet (low-carb, gluten free, vegan etc.)? If yes, please describe and reasons for following. 3. Who purchases and prepares your food? Weight History 1. What are your weight/body composition goals? LoseMaintainGain 2. How long have you been at your current weight? Other Please use this space to provide any other information you think we should know.