LIFESTYLE QUESTIONNAIRE Corinne Coaching
To book your Coaching Package, please complete and submit this form. Check your email for payment details. Thank you.
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First Name
Last Name
Please select the Coaching Package you require
Select an option
Personal Training Membership
Progressive Workout Programme
Building Balance Programme
121 Personal Training Sessions
Lifestyle & Behavioural Change Coaching
Unsure
Have you pre paid for your programme?
Yes
No
How did you pay?
Select an option
Bank Transfer
Cash
Occupation
How many hours do you work a week (on average) ...
How do you spend the majority of your time at work?
standing
sitting
driving
active
When you wake up are you ...
Tired and find it difficult to pull yourself out of bed
Refreshed and ready to start your day
How would you characterise your life?
highly stressful
moderately stressful
low in stress
What is your current body type?
underweight
ideal
slightly overweight
very overweight
What does your typical day look like? What Time do you wake up?
What time do you start work?
What time do you finish work?
What time do you go to bed?
How would you describe your current activity level?
sedentary
moderately active
active
highly active
How would your rate your present level of fitness
unfit
moderately fit
trained
highly trained
Have you ever had a personal training session?
Yes
No
Do you currently exercise?
Yes - please describe what you do in the notes below
No
Notes - what exercise do you do?
Only answer this section if you currently exercise. If you do not, please skip to the next section. How long have you been training?
A few weeks
A few months
Around a year
Over a year
How often do you train? (if applicable)
Once a week
2 x a week
3 x a week
4 x a week
5 x a week
6 x a week
Every Day
What type of exercise do you do? (if applicable)
Strength
Cardio
Flexibility
Other
How long is each session? (if applicable)
30 minutes
1 hour
1.5 hours
2 hours
Longer
Where do you exercise? (if applicable)
Gym
Home
Swimming Pool
Other
What time of the day do you usually train? (if applicable)
Morning
Afternoon
Evening
Do you participate is sports?
Yes - if so please elaborate in the notes below
No
Notes: what sports do you play and how often, are you in a team etc (if applicable)
What equipment do you have access to? (if applicable)
How much time will you be able to set aside to exercise each week?
1 hour
2 hours
3 hours
4 hours
More
What do you like LEAST about exercise?
What do you like MOST about exercise?
Do you regularly skip meals? Yes/No. If so indicate which ones
How many meals do you eat each day?
1
2
3
4
5
6
What time do you usually eat breakfast ?
What time do you snack in the morning?
What time do you eat lunch?
What time do you snack in the afternoon?
What time do you eat dinner?
What time do you snack in the evening?
How big do you say your meals were?
small
medium
large
extra large
Do you get hungry in between meals?
Yes
No
Do you take supplements?
Yes
No
Are you currently on a diet?
Yes
No
How would you rate your current eating habits ?
poor
average
good
How many portions of fruit do you eat a day?
1
2
3
4
5
more
How many portions of vegetables do you eat a day?
1
2
3
4
5
more
How many units of alcohol do you drink a week?
How many glasses of water do you drink each day?
1
2
3
4
5
6
7
8
More
What do you want exercise to do for you in the next 1 month?
What do you want exercise to do for you in the next 3 months?
What do you want exercise to do for you in the next year?
What goal is most important for you?
improve overall health
improve fitness
improve confidence
improve performance for a particular sport
improve moods and stress levels
improve flexibility
increase strength
increase energy levels
enjoyment
weight loss
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