New Client Questionnaire Your Details Section Buttons Name * Name First First Last Last Email * Birthdate (dd/mm/yyyy) * Which most closely describes your gender? * Female Male Non-Binary Agender/I don’t identify with any gender Prefer not to state Where do you live? (city and/or country) * How did you hear about Balanced Posture Online? * Google Search Friend/family/colleague Facebook Instagram Health Practitioner Referral Why have you decided to work/train with me? What are you hoping I can help you with the most? Next You & Exercise Section Buttons In general, do you enjoy exercising and being active? Yes, usually No, not usually Are you satisfied with your current fitness level? Yes, very happy with my fitness Somewhat, I could improve some areas Not really, I’ve become unfit the last few years No, I feel very unfit Which best describes your activity level? (vigorous = out of breath and/or sweaty; 7+/10 intensity) Very Active – 20 minutes of vigorous exercise 5-7 days a week Overall Active – 20 minutes of vigorous exercise 3-7 Active – 20 minutes of vigorous exercise 2-5 days a week Not Very Active – Less then 20 minutes of vigorous exercise 1-3 days a week Sedentary – no structured exercise at the moment What is your favourite way to exercise, or favourite activities? (gym, yoga, running, golf, etc) What exercises or activities do you enjoy the LEAST? What time of day do you prefer to exercise? Early Morning (before 7) Morning Lunchtime Late Afternoon 3-6pm Evening How many steps do you do most days? 12,000 or more 10-12,000 7-10,000 4-7,000 Less than 4,000 I have no idea What is your major obstacle to exercise or participating in activities? (check all that apply) Injury/Pain Time Money Self esteem and/or confidence Accessibility No idea how to get started or what to do Have you ever had a Personal Trainer or Coach before? No Yes A brief of description of your exercise history (eg. in the last 10 years, what has your routine looked like?) Next Injuries, Pain and General Health (Past and Present) Section Buttons Has injury or pain been a limiting factor in your exercise and fitness routine? Yes No Please describe your CURRENT injury or pain symptoms (what’s bothering you at the moment) Please describe your PREVIOUS injury or pain symptoms (what has bothered you in the past) Have you had any surgery, ever? No Are you on any current medications? No Have you got any current health or musculoskeletal conditions? (cardiovascular, arthritis, osteoporosis, tendinopathy, etc) Pregnancies and Labour – please share what you are comfortable sharing (# of pregnancies, # of births, type of labour(s), complications, on-going issues from pregnancy/labour, etc) What else would you like me to know about your physically health and limitations and your mental health? (whatever you are comfortable sharing with me) Next Your Lifestyle Section Buttons How many hours do you sleep each night? 3-5 5-6 6-7 7-8 8+ Do you wake up feeling rested? Usually Not usually Do you wake up during the night? Not usually 0-1 times 1-2 times yes, for 30-60mins (or more) How much coffee do you drink per day? 0 1 2 3+ How much water do you drink every day? Less than 1 Litre 1-1.5Litres 1.5-2Litres 2Litres or more How many alcoholic drinks do you consume each week? 0 1-2 2-4 4-7 8-14 14 or more What is your favourite way to unwind after a busy day? How would you rate your current stress levels? (1-very low, 10 – very high) 1 2 3 4 5 6 7 8 9 10 How do you deal with stress? (eg. eat chocolate, drink wine, call a friend) Do you have kids? No How often do you eat takeaway meals? 0-1/week 2-3/week 4-5/week 5+/week How happy you are in general day-to-day life? (0 never, 100 every minute of every day) Is there anything else you would like me to know? Let’s Get Started! Section Buttons Which option suits you best? Credit Card If you are human, leave this field blank. Submit Δ
