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PT Client Consultation

Birthday

Goals

What are your primary health goals? (Check all that apply)

Lifestyle and Activities

Does your job require physical activity?
No
Yes
How would you describe your current activity level?
Sedentary (little to no exercise)
Lightly active (light exercise 1-3 days/week)
Moderately active (moderate exercise 3-5 days/week)
Very active (hard exercise 6-7 days/week)
When was the last time you exercised?
With in the last week
With in the last month
With in the last 3 months
With in the last 6 months
Over 6 months ago
How many times a week can you commit to exercising?
1-2 days a week
3-4 days a week
5-7 days a week
Every day
Do you have any injuries or disabilities?
No
Yes
Have you ever felt dizzy or had chest pains whilst exercising?
No
Yes

Dietary Habits

How many meals do you typically eat per day?
1
2
3
4+
Do you have any regular snacks?
No
Yes
How often do you eat breakfast?
Daily
Occasionally
Rarely
Never
Do you eat out or order takeout frequently?
No
Yes
How much water do you drink daily?
None
Upto 1 litre
1-2 litres
3+ litres

Dietary Preferences and Restrictions

Do you follow any specific diet or eating pattern?
Vegetarian
Vegan
Paleo
Keto
Gluten-free
Other
Do you have any food allergies or intolerances?
No
Yes
Do you drink coffee?
No
Yes
Are there any foods you dislike or avoid?
No
Yes
Do you consume alcohol?
No
Yes
Do you use any dietary supplements (vitamins, minerals, protein powders, etc.)?
No
Yes

Health and Lifestyle

Do you have any medical conditions that affect your diet?
No
Yes
Do you have any digestive issues (e.g., bloating, constipation)?
No
Yes
How would you rate your current energy levels?
Very high
High
Average
Low
Very low
How many hours of sleep do you get per night?
Less the 5
5-6
7-8
8+

Motivation

On a scale of 1-10, how motivated are you to achieve these goals?
1-2 (very low)
3-4
5-6
7-8
9-10 (very high)
What do you believe are the biggest challenges to achieving your health goals?
Lack of knowledge
Time management
Cravings/ emotional eating
Social events
Other
Have you tried any diets or programs in the past?
No
Yes
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