Lifestyle Questionnaire
Lifestyle MOT Questionnaire
First Name
*
Surname
*
Address
Email Address
*
Mobile
Gender
*
Male
Female
Prefer Not To Say
Date of birth ( DD / MMM / YYYY )
*
Occupation
How fit would you say you are?
I don't train / Hardly Any
Train 1-2 times a week
I like training (3-5 times a week)
Fitness freak (train 5 + times a week, live & breath fitness)
Do you like cooking?
Yes
No
Love it
Do you eat out much?
Yes
No
Occasionally
Do you drink alcohol?
*
Yes
No
Occasionally
Do you smoke?
Yes, socially
Yes, more than 10 a day
No
How stressed would you say you are on a regular basis from 1 to 10?
*
1
2
3
4
5 Stressed
6
7 Anxious
8
9
10 Depressed
How much water do you drink?
Hardly any
1-2 L a day
2 L + a day
How much sleep do you get?
Hardly any
4-5h
5-6h
7h +
How good would you say your diet is?
*
Out Of Control
Moderate
Good
Bang On
How many times a day do you usual eat?
*
Do you skip meals?
*
Yes
No
Sometimes
Do you eat late at night?
*
No
Sometimes
Quite Often
Do you have children? ( if yes please say how many )
*
What is your home life like? ( busy, quiet, always on the go etc. )
*
In what areas of food do you struggle with? ( if yes please elaborate )
*
Do you have any medical conditions? (if yes please elaborate)
*
Do you take any tablets? (if yes please say what)
Do you have any allergies? (if yes please say what)
*
What sort of exercises do you enjoy?
*
What sort of exercise do you dislike?
*
Where do you prefer to train?
*
Home
Gym
Group Training / Crossfit / Bootcamp
Outdoors
How many hours a week can you invest in your training?
*
1-2
2-3
3-4
Everyday
Do you have any habits that don't serve you? ( if yes please elaborate )
*
Do you consider yourself overweight?
Yes
No
What is your goal/ ideal weight?
*
What energy animal are you?
Early Bird
Night Owl
Would anything in particular increase your motivation to change your weight? ( please give me more details )
*
Do you have any problem areas e.g weak knee, bad back etc? (if yes please elaborate )
*
How motivated would you say you are from 1 to 10?
*
1
2
3
4
5
6
7
8
9
10
Are you full of energy throughout the day?
Yes
No
What are your frustrations ( fitness/lifestyle wise) e.g: body conscious, clothes don't fit, no sex drive, no energy, etc
Where do you struggle the most? e.g: lack of motivation, knowledge, time, meal preparation, etc..
How important to you is your health?
*
1. I don't care about my health
2. I love myself and I will do whatever it takes to look after my body
Are you willing to invest in yourself?
*
Yes
No
What are your short term goals? ( 12 weeks )
*
What are your long term goals? ( 6 months + )
*
How committed are you in achieving your goal from 1 to 10?
*
1
2
3
4
5
6
7
8
9
10
How do you feel PHYSICALLY at the moment?
How do you feel MENTALLY at the moment?
Have you tried other diets before? (if yes please elaborate)
What went wrong with that?
What motivates/ inspires you?
Are you ready to change if needed?
*
Yes
No
Yes, small changes
I hate change
Have you tried to train on your own before?
Yes
No
Long time ago
If yes, how did that go?
Why do you think some fitness programs or diets fail?
How often would you say you watch TV? Or are in front of a screen?
*
Are you easily influenced by others?
Yes
No
Do you crave sugar?
Yes
No
Do you need help with your mindset?
*
Yes
No
What are your expectations from THE BODY HACKER?
reCAPTCHA
Submit
