Physical Readiness and Nutrition Questionnaire

Step 1 of 8 - ___Basic Info___

12%

Your Name(Required)

First Last

Participants Email(Required)

Please use the email of the participant, even if this was a gift or purchased under a separate email

Have you read the "90 Day habit Transformation" Book?(Required)

I would like to know if you are versed in the approach, philosophy and vernacular found in the book

Yes, I have read the book

No, I have not read the book

How did you hear about Forge Fitness and Nutrition Coaching?(Required)

As a small, privately held company that is self-funded, it is very important for us to understand where our new clients learn about us. Your contribution to this question is greatly appreciated by our whole team!

Web Search

Google Ad

Facebook

Instagram

You Tube

Podcast

News Outlet

Referral

Other

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Your Age(Required)

Birth Gender(Required)

Height (In Inches)(Required)

Current Weight (lbs)(Required)

Rate your overall activity level(Required)

Sedentary

Moderately active

Active

Very Active

Competitor

Primary Fitness Goal(Required)

Please select the option that you feel is most critical to address immediately based on your perspective. This will allow your Coach to assess where to start but keep in mind, what you indicate here will change as you progress!

Reduce Excess Body Fat

Gain Lean Muscle

Refine Current Efforts

Post Injury Rehabilitation

Athletic Development or Performance

Improve Mobility, Flexibility and Stabilization

Other

What is Your Long-Term Fitness or Nutrition Goals?

Any additional short and long-term goals will help your Coach consider how to best structure your training, nutrition and intensity.

Physical Readiness(Required)

Please Check All That Apply. If None, Click "None of The Above" and continue

Has your doctor ever said that you have a heart condition and that you should limit activity?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs for your blood pressure or heart condition?

NONE OF THE ABOVE

General Medical Condition(Required)

Please Check All That Apply. If None, Click "None of The Above" and continue

Heart Condition

Asthma-uncontrolled

Shortness of Breath

Arthritis Bursitis

Osteoarthritis

Rheumatism

Hernia

Recent Surgery

Sacroiliac Problems

Angina

High Blood Pressure

Knee Problems

Back Problems

NONE OF THE ABOVE

Are You Currently Taking Any Medications?

Please note that your Coach will not provide prescriptions in any form with the intention of curing, treating, or preventing disease. However, knowing what medications you are taking can help your Coach optimize your custom program.

Do You Have Any Injuries That Affect Exercise?

Please include detail about acute or chronic injuries. These can be sport related, impact, overuse, occupational or any other biomechanical issue that could impede or delay your progress. The more you share with your Coach, the better equipped they will be to assist you.

Describe your occupation and typical workday

Your Coach will want to understand your daily physical stress, sitting periods, potential overuse in biomechanical operations or any other factors that could alter how they customize your program.

How Many Hours Each Day Do You Sit?

Sitting has severe consequences in your dynamic and static movements and your Coach will want to have an idea of your sedentariness or hours spent in seated positions and this may affect your physiological function.

Less Than 1 Hour

2 - 4 Hours

4 - 6 Hours

More Than 6 Hours

What Kind of Shoes Do You Wear Most Often?

Shoes with excessive heel or arch support may alter general human movement and can be a factor in determining stretching, mobility, and functional moments in your program.

Flat Shoes

Athletic Shoes

Mid-Heel Dress Shoes

High Heels / Heeled Boots

How Would You Rate The Stress Level Of Your Job?

Stress factors may impede your progress physically and emotionally. Your Coach will want to understand your stress levels to apply the appropriate amount of intensity to your program.

1 - Not Stressful

2 - Moderatly Stressful

3 - Short Periods of High Stress

4 - Long Periods of High Stress

5 - Stress In a Constant Potential Life Threatening Environment

What, If Any, Are Your Hobbies?

Listing your hobbies will help your Coach understand any additional activity, repetitive movements or non-work-related periods of sedentary time.

Athletics, Sports & Recreation

In this section, please share the sport or recreational activities in which you participate. If you are an advanced athlete and require or desire sports specific training or corrective exercise please explain your needs in the “Additional Details” section at the bottom of this page. If you are not necessarily an advanced athlete but would like to participate in one of the Sport's below please indicate your desire in the “Additional Detail” section at the bottom of the page.

American Football

Baseball

Basketball

Ice Hockey

Soccer

Tennis

Golf

MMA or Wrestling

Marathon Athlete

Triathlon Athlete

Hiking - Back Country

Oar or Paddle Boating

Tough Mudder, Spartan or Other Hybrid Event

3,k, 5k or 10k Runs (Leisure or Competitive)

Any Other Sport or Activity Not Listed:

Additional Details - Please Specify Needs Related to Your Sport

Please describe your current activity or workouts

What form of cardio do you like best?

Running - Outside

Walking - Outside

Running - Treadmill

Walking - Treadmill

Elliptical Trainer

Stationary Bike

Recumbent Bike

Stair Climber

Other

How Would Your Rate The Quality of Your Nutrition?

Very Poor (Fast Food, Microwave Meals, Soda, or Sweets)

Poor (Some Fast Food, Occasional Microwave Meals, Soda, and sweets)

Average (Rarely eat Fast Food or Microwave Meals, Occasional Soda and Sweets)

Mildly Healthy (Almost No Fast Food or Microwave Meals. Rare Soda or Sweets)

Healthy (No Fast Food or Microwave Meals. No Sods and Rare Sweets)

How Many Alcoholic Beverages Do You Consume Weekly?

None

1-3

3-6

6 or more

What equipment do you have access to?(Required)

Free weights (dumbbell/barbells)

Gym machines (Freemotion, Precor, Cybex, etc.)

Cable machines

Resistance bands

Bosu ball

Stability ball

Kettlebells

Suspension training (TRX)

Bowflex or other home gym

No equipment

Please Check All That Apply

Please Describe Your Training Enviroment

Dietary Preferences(Required)

What Days Do You Plan To Work Out

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How Frequently Do You Expect To Exercise

1 - 3 days each week

4 - 5 days each week

6 - 7 days each week

I plan to follow the recommendation of my Coach

Is there anything else you would like your Coach to know?

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90DHT - Physical Readiness and Nutrition Questionnaire

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