New Member Questionnaire
This is a feedback form I’ve used with personal clients and Transformation Contest clients.
It tells me a lot about what might be causing plateaus, injuries, etc. And it helps me help them get results so much faster. If you are a Turbulence Training member, you can fill out this form in the forum and we can review your information together to help you get the right program and diet for your goals.
Now while I certainly can’t review everyone’s form here on the blog, I really believe that you’ll discover a LOT about yourself if you take about 10 minutes to fill out this form on your own. Just copy it, print it, and sit down and fill out as much info as you can. If you don’t have all the health info, it probably means you need to see your doctor.
By the way, it would be a great idea for everyone who is entering a Transformation Contest or who trains with a trainer to fill out the form and give it to your trainer. Having this info will help them help you better.
Hope this helps,
Craig Ballantyne, CSCS, MS
***********************
HEALTH BACKGROUND
Forum Name:
Please take a “Before Photo” at this time and every 4 weeks from now on.
Age: ________________
Height: ______________
Weight: ______________
Resting heart rate: _______
Blood pressure: ______________
Body fat %: ____________
CIRCUMFERENCE MEASUREMENTS (inches) – Taken in relaxed state:
Waist (At navel): _____Mid-Upper Arm:_______Mid-Thigh: ________Hip Circumference (Widest point between legs & navel):____________
Last time you visited your doctor: ______________________________________________________
List any medical conditions that would/do prevent certain exercises: ______________________________
List any conditions/injuries that would/do prevent certain exercises: ______________________________
Do any exercises cause you pain or discomfort: _____________________________________________
Do you now experience, or in the past 6 months have you suffered from, any of the following conditions? Highlight where applicable, and indicate Right (R) or Left (L)
Neck Problems: ___________________________
Lower Back Problems: _______________________
High Blood Pressure: ________________________
Diabetes: _________________________________
Shoulder Problems: __________________________
Hip Problems: ______________________________
Asthma: __________________________________
High Cholesterol: ____________________________
Elbow Problems: ____________________________
Knee Problems: _____________________________
Heart Problems: _____________________________
Smoking History: ____________________________
Wrist Problems: _____________________________
Foot/Ankle Problems: _________________________
Food Allergies: ______________________________
Upper Back Problems: _________________________
Arthritis/Carpal TS: __________________________
Dizziness: _________________________________
Chronic Conditions (other): _____________________
Self-Assessment & Goal Setting – Rate your current status on a scale of 1 to 10 (1 = needs improvement & 10 = optimal)
Strength: ___________________ Endurance: __________________
Body composition:______________ Overall physical condition: __________
Athletic Mobility:__________________
List Your Performance Strengths & Weaknesses-Physical & Mental:
Strengths: _____________________________________________________________
Weaknesses: ___________________________________________________________
State your personal philosophy on life or source of motivation in life:
_____________________________________________________________________
_____________________________________________________________________
TRAINING GOALS – Be very specific
Three Short term goals:
1. ______________________________________
2. ______________________________________
3. ______________________________________
Three Long term goals:
1. ______________________________________
2. ______________________________________
3. ______________________________________
WORKOUT QUESTIONS:
What past program has given you the best results: __________________________________________
What past program has NOT worked for you: _____________________________________________
Overall intensity level of current workouts on a scale of 1 (low) to 10 (high): ________________________
General physical feeling during exercise: ________________________________________________
What time of day do you workout? __________________________
OUTLINE WEIGHT TRAINING SESSION
Number per week:____________________________
Volume per session (# of sets and reps): _____________
Exercises performed:___________________________
Length of rest interval between sets: ________________
Intensity level: _______________________________
Body parts trained:____________________________
Number of rest days:___________________________
AEROBIC EXERCISE SESSION
Mode of exercise:_______________
Duration of exercise: _____________
Intensity of exercise: _____________
Frequency of exercise: _____________
Please comment on your experiences with any of the following:
Body resistance strength training, exercise bands/surgical tubing:_______________________________
Yoga/breathing techniques, medicine ball training, Stability ball/balance training:____________________
Plyometrics, interval training: _______________________________________________________
What exercises do you like within your current routine: ______________________________________
What exercises do you dislike within your routine: __________________________________________
Are you willing to try new or unconventional exercise techniques in order to exercise more effectively: ______
Are there sports that you like/would like to play, train for, or add to your program: ____________________
HOW MUCH TIME WILL YOU COMMIT TO TRAINING?
Days per week: _____________________
Time per session: ____________________
Rate commitment level on a scale of 1 (low) to 10 (high): ___________
LIFESTYLE QUESTIONS:
What is your dominant hand: _____________________________________________
Do you swing and shoot right-handed or left-handed: _____________________________
What is your dominant leg (what leg do you support your bodyweight with): _____________
Do you stand or sit with your shoulders “shrugged up: _____________________________
Can you lift both hands straight overhead without difficulty or pain: _____________________
Are there any things in day to day life that irritate your body or joints? For example, does it hurt your shoulders or back to sit for prolonged periods of time: ______________________________________________________________________
Do you perform any activities with a rounded back: ___________________________________
Outline your sleeping schedule during the week & on the weekends:________________________
How many hours of sleep do you get on average:______________________________________
Rate the quality of your sleep (1 = poor, 10 = perfect): __________________________________
NUTRITION:
What past nutrition program has given you the best results:_________________________________________
What past nutrition program has NOT worked for you:____________________________________________
Complete a food log on www.fitday.com for 2 weekdays and 1 weekend day. Send me the login and password for the food log so that I can review it. In addition, fill out the following sheet outlining your daily food intake. Include detailed proportions, time of intake, reasons for eating (hungry, bored, social), water intake, caffeine use, supplement use, and alcohol intake (if applicable).
Weekday Breakfast (Time ___): _____________________________________
Weekday Snack (Time ___): ________________________________________
Weekday Lunch (Time ___): ________________________________________
Weekday Snack (Time ___): ________________________________________
Weekday Dinner (Time ___): ________________________________________
Weekday Snack (Time ___): _________________________________________
Weekend Breakfast (Time ___): _______________________________________
Weekend Snack (Time ___): _________________________________________
Weekend Lunch (Time ___): _________________________________________
Weekend Snack (Time ___): _________________________________________
Weekend Dinner (Time ___): _________________________________________
Weekend Snack (Time ___): __________________________________________
List all the obstacles that would get in the way of health eating: ____________________
List 2 solutions for each obstacle:
1)_________________________________________________________________
2)__________________________________________________________________
What foods do you like: ___________________________________________________
What foods do you dislike or do not agree with you: ________________________________
What foods do you not want to give up: _________________________________________
Do you eat a lot of fruits and vegetables: _________________________________________
How often do you eat fast food: _______________________________________________
How do you feel after you eat fast food: __________________________________________
Do any foods give you energy or cause a decrease in energy and make you tired: _______________
How do you feel after you eat foods containing a lot of sugar: _____________________________
How do you feel after you eat foods containing a lot of fat: _______________________________
How much caffeine do you consume per day? How do you feel after you have caffeine: ____________
ENERGY
Describe your present energy levels during a typical day: ___________________________________
How are your energy levels when you wake up:__________________________________________
How are your energy levels after lunch: _______________________________________________
How are your energy levels after school/work: __________________________________________
How are your energy levels in the evening: _____________________________________________
How are your energy levels on the weekend compared to the weekdays: __________________________
How are your energy levels on the day of competition (if applicable): ____________________________
Thanks for filling out this comprehensive data sheet to help me provide you with the best training program and lifestyle plan.
Sincerely,
__________________
Craig Ballantyne, CSCS, MS
Author, Turbulence Training for Fat Loss
CB Athletic Consulting, Inc.