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Thank you for filling out this in-depth questionaire and helping me to better understand your life and goals. If at any point you feel that the question is too personal or you do not have an answer, skip it. However, the more in depth your answers are, the more I will be able to understand your story and build a program that is right for you. Just remember, something brought you to this page. There is something you are not getting out of life. Help me to understand what this is. Here at CEC, you are more than just a paid client - you are now family and we want to do everything possible to get you on track to living your best life. You may notice that some of these questions sound similar. The purpose for this is that as you answer questions, it opens your mind to answers you did not know you had. Thanks again!

Name

First Name

Last Name

Phone

(###)

###

####

Age

Gender

Weight

Height

Where do you live?

What is your why?

What do you want to accomplish in life?

What do you want out of life that you are currently not getting?

Have you ever been in good shape?

If so, when?

Do you have a gym membership or intend to get one for this program?

If so, which gym?

Do you have a home gym?

If so, what equipment do you own?

Do you have a dog/pet that requires being walked consistently?

Did you play sports in high school/college?

If so, what sport(s)?

What physical activities do you enjoy doing?

Are you part of any recreation leagues?

If so, what kind?

On a scale from 1-10, where would you rate your current health?

1 being worst, 10 being best.

Please elaborate on your last answer.

On a scale from 1-10, where would you rate your overall physical fitness?

1 being worst, 10 being best.

Please elaborate on your last answer.

Relationship status

On a scale from 1-10, where would you rate your children’s current activity levels?

1 being worst, 10 being best.

Please elaborate on your last answer.

What barriers do you believe are stopping you from achieving your current goals?

What are your current goals?

If you do not have any, why?

What do you find yourself doing most in your free time?

This excludes time working and fulfilling obligations.

What does a typical day of eating look like for you?

How many calories do you think you consume on an average day?

Take your best guess.

How many calories do you think your body burns in a day?

Take your best guess.

What are your favorite snack foods?

What are your favorite healthy foods?

Do you look at the label before purchasing a food item?

Where do you do your grocery shopping?

Do you own a bicycle?

How far is the closest park to your home?

Are there hiking or walking trails near your home?

Do you have any concerning health or medical problems?

If so, what are they?

Have you been cleared by your doctor to participate in regular exercise?

True or False: The leading cause of death in the world, heart disease, is preventable through slight life modifications.

Have you ever attempted to diet before?

If yes, what were your biggest successes and/or struggles?

Have you ever attempted a workout program from someone else before?

If yes, why did it not work out?

What is your WHY for getting your life back on track?

Do you struggle to save money monthly?

Do you feel as if you need a second source of income?

Do you own or rent your home?

If you rent, how long have you been renting?

What do you want most from a program like this?

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