Fit with "FUSS" header Fit with "Fuss" Transformation Challenge

Fit with Fuss Survey Form

First Name (required)

Last Name (required)

Your Email (required)

Your Home Phone Number (required)

Your Cell Phone Number (required)

Best time to contact by phone?
 Morning Afternoon Evening

 YES! Please send more information about FIT with "FUSS" and Fuzion Formula Fitness.

1. Why are you completing this questionnaire? Please check all that apply
 I am a new FIT with "FUSS" client. I am interested in personal training or fitness consulting with FIT with "FUSS". I am interested in nutritional guidance or a customized nutritional supplement program from FIT with “FUSS”.

2. Why are you looking for a personal fitness trainer or nutritional program? Please check all that apply.
 Fat or weight loss Muscle gain Bored with workouts Want to learn more about fitness and/or nutrition Recommended by physician, physical therapist or other healthcare professional Sports-specific training Other

3. Please provide a brief description of the health and fitness goals you are trying to achieve or improve.

4. How are your energy levels throughout the day?
 High Moderate Low

5. Do you need more energy or stamina during your workouts?
 Yes No

6. Do you get sleepy or lethargic after eating?
 Yes No

7. How many meals do you eat per day?
 1 2 3 4 5 6 or more

8. Do you skip meals? If you skip meals, check which ones you skip on most days?
 No Breakfast Lunch Dinner

9. What time do you eat breakfast, lunch and dinner?

10. Do you eat snacks? If you eat snacks, check all snack times that apply?
 No Yes. Between breakfast and lunch. Yes. Between lunch and dinner. Yes. Between dinner and bedtime. Middle of the night.

11. What do you normally eat before and after workouts?

12. How many times per week do you eat fatty, fast or fried foods?
 Never 1 2 3 4 5 or more

13. Do you crave sweets or carbohydrates?
 Yes No

14. How many servings of fruits and vegetables do you eat daily? (A serving equals 1/2 cup of cooked or raw vegetables, 1 cup of leafy vegetables, 1/2 cup of fresh, frozen or cooked fruit or 1/4 cup of dried fruit.)
 None 1 2 3 4 5 or more

15. How many cups of coffee, tea, soda or other caffeinated beverages do you consume each day?
 None 1 2 3 4 5 or more

16. List all food allergies including lactose intolerance.

17. Are you currently dieting?
 Yes No

18. Are you currently or have you ever taken any product to enhance weight loss?
 Yes No

19. Would you be interested in purchasing personalized, nutrition sessions or phone coaching from a registered dietitian to help you reach your nutritional goals?
 Yes No

20. Do you currently take any over the counter vitamins or nutritional supplements? Check the vitamins you are currently taking.
 No Multi-vitamin Vitamin C Antioxidants Essential Fatty Acids Calcium Iron

21. List any other vitamins or nutritional supplements (including protein shakes or bars and creatine) that you are now taking below.

22. Do you desire increased anti-oxidant protection?
 Yes No

23. Would you be interested in a customized, daily vitamin supplement formulated specifically for your body type?
 Yes No

24. Are you currently participating in an exercise program?
 Yes No

25. Do you currently have access to a gym facility or have an active membership with a health club? If yes, check the facility you train at.
 No Yes - Goodlife Fitness Yes - YMCA/YWCA Yes - Curzons/Premier Fitness Other

26. How many times a week are you doing some type of cardiovascular fitness (walking, jogging or exercising)?
 None 1 2 3 4 5 or more

27. Check the types of cardiovascular fitness you currently participate in.
 Walking Jogging/Running Treadmill Ellipitical Training Stationary Bike Recumbent Bike Bicycle Aerobic Class Other

28. Are you currently weight training as a part of your exercise program? If you are weight training, indicate what type of equipment you are using.
 No Yes - no equipment Yes - free weights Yes - machines Yes - other

29. Please list all sports you are currently involved in?

30. What muscles fatigue quickly while weight training? Check all that apply.
 Abdominals Hamstrings Quadriceps (thighs) Calves Chest Neck Upper Back Mid Back Low Back Shoulders Biceps Triceps

31. Do have any problems with muscle cramping during exercise or workouts?
 Yes No

32. What time do you exercise each day?
 Morning Afternoon Evening

33. Do you currently suffer from any joint pain from a previous injury (tendon, ligament, cartilage, etc.) that prevents you from being as active as you would like?
 Yes No

34. Is there any reason at all (health or personal) that would limit or prevent you from exercising? If you have exercise limitations, please list the reasons you can’t exercise.

35. What time do you usually go to bed and wake up?

36. Do have insomnia or trouble sleeping?
 Yes No

37. Please provide your height, current weight and weight 1 year ago.

38. Do you smoke? If so, how many packs a day?

39. Do you drink alcohol? If so, how many drinks a day?

40. Do you have any of the following medical conditions?
 Cholesterol over 200 Weak bones and/or joints Asthma Diabetes Hyper Thyroid Hypo Thyroid High Blood Pressure Coronary Artery Disease Heart Problems Osteoporosis Osteoarthritis Fibromyalgia Attention Deficit Disorder (ADD) Anxiety

41. Do you consider yourself to have a high stress level?

42. Are you currently taking any prescription medications? If so, please list them including dosage.

43. Have you had surgery in the last year? If so, please indicate procedure.

44. Are you post-menopausal?
 Yes No

45. Do you suffer from hot flashes?
 Yes No

46. Are you pregnant or lactating? If pregnant, please include due date.

47. How much weight would you like to lose or gain?

48.*It is strongly advised that you seek the advice of your physician before starting any exercise program.
Date:

49. Client Signature