Do you give PF4U Coaches permission to CALL or TEXT the phone number provided above?* ---YesNo
On average, how many days per week do you work?*
On average, how many hours per day do you work?*
Are you within 5 days of your last period?* ---YesNoUnsureN/A
Your current body fat percentage (if known)
How active/sedentary will your TYPICAL day be on a scale of 1-10* Aside from the gym- 1 being sedentary and 10 being very active. Sedentary meaning: spend most of your day sitting. Lightly Active meaning: Spend part of your day on your feet. Active meaning: Spend part of the day doing physical activity. Very Active meaning: Doing physical activity for the majority of the day. ---12345678910
On a scale of 1-10, how would you rate your CURRENT fitness level (1=worst, 10=best)?* ---12345678910
How did you hear about #Perfectfit4u?* ---InstagramFacebookSnapChatWord of MouthStore SignWebsiteOther
If you chose WORD OF MOUTH or OTHER for the above question, please let us know WHO referred you, we would love to thank them!
Current Health Information - Par-Q Form If you answer "Yes" to any of the following questions, we will require a doctor's note prior to beginning your training program.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?* ---YesNo
Do you feel pain in your chest when you do physical activity?* ---YesNo
In the past month, have you had chest pain when you were not doing physical activity? * ---YesNo
Do you lose balance because of dizziness or do you ever lose consciousness?* Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). ---YesNo
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program?*
Are you currently pregnant or breastfeeding?* ---N/ANoYes
Have you had a recent surgery?* If Yes, please explain. ---YesNo
Do you take any medications, either prescription or non-prescription, on a regular basis?*
What is the medication for?
Do you know of any other reason why you should not do physical activity?*
If you marked yes to any of the above, please explain
Do you smoke? If yes, how much?* ---YesNo
Do you drink alcohol? If yes, how much?* ---YesNo
Does your occupation require you to travel often?*
How many hours of sleep do you receive PER night (on average)?*
What are your favourite activities/hobbies?*
On a scale from 1-10, how would you rate your stress level?* (1=worst, 10=best)?* ---12345678910
Please list YOUR 3 biggest CURRENT sources of stress?*
Developing Your Fitness Program
How often do you CURRENTLY take part in physical exercise?*
Realistically, how often would you like to exercise during your program?*
Realistically, how much time would you like to spend during each exercise session?* ---30 min45 min60 min60+ min
Do you prefer to execute your workouts from HOME? If YES, what equipment do you have available?* ---YesNo
Please send PHOTOS (email@example.com) and a LIST of the equipment that you have at your disposal.
What are the best times for you to exercise?* ---MorningAfternoonNight
Do you CURRENTLY have or PLAN ON obtaining a gym membership while participating in your Perfectfit4u Program?* ---YesNo
If so, WHAT gym?
Do you prefer to execute SOME of your workouts at HOME and SOME of your workouts in the GYM?* ---YesNo
If YES, how many times per week could you devote to the gym? And how many days could you devote to home workouts?
Please list in order of priority, the goals you would like to achieve through implementation of this program:*
On a scale of 1-5, where do you CURRENTLY rate your HEALTH as a priority in your life?* (1=Unhealthy, 3=Average, 5=Good) ---12345
On a scale from 1-5, where does your SPOUSE/FAMILY/CHILDREN/SUPPORT SYSTEM rate HEALTH as a priority in THEIR lives?* ---12345
Nutrition Information Please answer YES or NO to the following questions, unless otherwise stated:
On a scale from 1-5, how would you CURRENTLY rate your nutrition/eating habits?* (1=Poor, 5=Excellent) ---12345
Do you have any food ALLERGIES?* (Ex. Celiac, Lactose Intolerance, etc.) If "Yes", please explain below. ---YesNo
Do you have any foods that you refuse to eat due to taste aversion? Please CHECK any foods you REFUSE to eat from the list below.* Chicken Breast, Lean Ground ChickenTurkey Breast, Lean GroundTurkeyEggs, Egg WhitesTilapiaCodShrimpCanned TunaHaddockHalibutSalmonBeef (Steak or Ground)YogurtCottage CheeseProtein PowdersProtein BarsOatsCream of WheatCereals, GranolasRice Cakes, MelbaToasts, CornThins, Rice CrackersRiceQuinoaCouscousMilletSweet PotatoesWhite PotatoesPasta/NoodlesBread & WrapsBeans (Black, Pinto, Kidney)Berries (Strawberries, Blueberries, Blackberries, Raspberries, etc)Tropical Fruits (Banana, Mango, Pineapple, Grapes, Kiwi etc.)Melons (Cantaloupe, Honeydew, etc.)Seeds (Chia, Flax, etc.)Nuts (Almonds, Pecans, Cashews, Brazil Nuts, etc.)Nut Butters (Peanut, Almond, Cashew)Avocado/GuacamoleCream CheeseOlive OilCoconut OilI am open to anything
What are some of your favourite foods?
Please list some of your most highly consumed foods on a daily basis?
Do you have a preferred dieting method that has been proven to work for you in the past? If so, please explain (Ex. Paleo, Vegan, Vegetarian, etc.) Feel free to explain further if needed. *
How many times throughout the day do you eat CURRENTLY (on average)?*
How many litres of water do you consume daily on AVERAGE?*
Do you tend to skip meals despite being hungry?* ---YesNoSometimes
Have you ever been diagnosed or struggled with an eating disorder of any type? (Bulimia, Anorexia, BED, etc.)* ---YesNo
Do you CURRENTLY eat breakfast religiously?* ---YesNo
Do you CURRENTLY tend to eat late at night?* ---YesNo
Have you ever tracked your food intake (i.e. food diary)?* ---YesNo
How familiar are you with "macros" and "macro counting"?* (1=Poor, 5=Excellent) 12345
Are you currently taking specific vitamins or any other supplements? Please include them below.* ---YesNo
Do you do your OWN cooking?* ---YesNoSometimes
How important is it for you to be able to cook meals for your family members?* (1=not very, 5=every meal) 12345
Do you do your OWN grocery shopping?* ---YesNo
Please describe your daily eating schedule/routine.*
What appliances do you have at your disposal for food preparation on a typical weekday?* (i.e. Stove, Oven, Toaster, Blender, Microwave, etc.)
Besides hunger, for what other reasons do you EAT?* BoredSocialStressedTiredDepressedHappyNervousOther
Please Explain The Type Of Coach You Want
Describe your ideal coach or what exactly you'd expect from an ideal coach.*
Would you like a membership to the Perfectfit4u App which includes a PRO membership that allows clients to track their food intake and body metrics/progress as well as receive access to workout demo videos of their programs. Login information will be provided with your first program.* (for iPhone or Android) for $3.99/month?* ---YesNo
Please list anything else that you may feel is a concern or information that has not been disclosed that you feel our staff should know in order to develop the program best suited for you.
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Your Email (required)