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Susie Bergman
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About
Contact
Lifestyle Questionnaire
Lifestyle Questionnaire
Name
*
First Name
Last Name
Date
MM
DD
YYYY
Lifestyle
How would you rate your current stress level (Low/Med/High)? If high, please explain.
How many hours of sleep do you get per night (on average)?
Do you wake up frequently or have sleeping issues? If yes, please explain.
How many alcoholic beverages do you consume per day? Per week?
How many hours a week do you work?
Do you travel for work? If so, how much? International or bicoastal? How often?
Training
How many days/week can you realistically workout? How many minutes/day?
What are your training goals? Write as much as you want here! More details = a more specific and motivating program for you. General goals are “I want to be more fit and healthy,” but more specific goals are “I want to do 3 pull ups” or “I want to lift my kids up without worrying about hurting my back.”
What is your movement/exercise/sports history? Please list everything you can remember.
What have you been doing for the past 6 months?
Please list any injuries or medical conditions which may affect your training. Please also include whether you have seen specialists for these injuries/conditions.
Thank you!