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1. Are you Vegetarian, vegan, not eating meat, or on any special diet?
 Yes No
If yes, please give details here:

2. On average, how many litres of water do you drink daily?
 3 Litres or More 1-2 Litres Less than 1

3. On average, how many caffeinated drinks do you drink daily (coffee, tea, coke..)?
 More than 4 2-4 Less than 2 None

4. How often do eat processed food, ready made meals?
 Every Day Almost Always Occasionally Never

5. Approximately, how many meals do you eat daily?
 5 or more 4 3 2 or less

6. How often do you consume alcoholic beverages?
 Every Day Few days per week Never

7. On average, how many meals do you eat out daily?
 3 or more 1-2 Hardly ever


1. How many days per week do you exercise?
 Every Day 3-5 days 1-2 days Rarely

2. How many days per week do you strength train?
 4-5 days 2-3 days I don't strength train

Describe your routine:

3. Do you regularly perform cardiovascular exercise? If so, how many days per week?
 6-7 days 4-5 days 2-3 days 1 or fewer

4. What would you consider a “barrier” that prevents you from daily exercise? (ie: Time, lack of facilities etc.)


Rank your goals in undertaking a fitness program. What do you want this program to do for you? Use the following scale to rate each goal separately.

Not at all important Somewhat important Extremely Important
1 2 3 4 5

Improve cardiovascular fitness:

Body-fat weight loss:

Improve performance for a specific sport:

Improve flexibility:

Increase strength:

Increase energy level:

Feel better:


Reduce stress:

Pain relief:

Lose weight/inches:

Gain weight/muscle:

Improve quality of life:

Improve overall health:

Improve appearance:


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