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Health & Goal Questionnaire
Synergy Fitness - Lifestyle and Daily Habits Questionnaire
First Name
Last Name
Date
Email Address
Phone
Age
Height
Current Weight
Goal Weight
Do you currently take a daily multi-vitamin?
Yes
No
Do you eat a large variety of fresh produce every day?
Yes
No
Do you experience any bloating regularly?
Yes
No
Do you experience any type of joint pain?
Yes
No
Have you been on a calorie restricted diet for weight loss at any point during the past year?
Yes
No
Do you have a goal of losing more body fat?
Yes
No
Do you feel like you could use more energy and drive during your workouts?
Yes
No
Do you feel like you are always sore after your workouts?
Yes
No
Do you want to gain muscle tone and definition?
Yes
No
Do you feel like your energy is high and stable throughout the day?
Yes
No
Do you want to improve your metabolism so your body can burn more calories?
Yes
No
Do you want to improve the tightness and elasticity of your skin?
Yes
No
Have you ever experienced a plateau with your fitness progress?
Yes
No
Do you sleep at least 7 hours each night?
Yes
No
Do you have a hard time falling asleep?
Yes
No
Do you sleep through the night?
Yes
No
Do you feel tired in the morning after sleep?
Yes
No
Do you find yourself hungry at night or wanting to snack?
Yes
No
Do you have any stress in your life?
Yes
No
Number these in order of importance to you (1-6): Weight Loss, Improving Energy Levels, Body Fat Reduction, Strength and Endurance, Toning and Tightening, Boosting Confidence
How long have you been trying to get to your ideal body / ideal weight?
3-6 Months
6-12 Months
1-2 Years
2-5 Years
5-10 Years
More Than 10 Years
What is your current body fat percentage?
What is your body fat percentage goal?
When do you want to accomplish this goal by?
How long do you think it would take you to reach that goal on your own?
Are you consistently training 3 times per week for 30 minutes?
Yes
No
Are you following your meal plan 90% of the time or more?
Yes
No
What is the one BIG thing preventing you from being at your ultimate goal right now?
Please list all supplements (not medications) you are currently taking daily
How did you hear about us?
Submit Questionnaire
Fill in our PAR-Q (Physical Activity Readiness Questionnaire) as well.
Fill out PAR-Q
