Initial Assessment Questionnaire

Required for new clients

Initial assessment questionnaire.

Complete all sections before requesting a free 15-minute consultation. Write “None” where a question does not apply. If you are on a GLP-1 program, answer “Yes” below and complete the extra GLP-1 sections so Mike can build your training around it. Your answers are not stored on this page; you will review and send them to Mike by email before continuing to available times.

1. Personal information

Full name

Age

Gender

Best phone number to reach you

Email address

Home address

2. Health and medical history

Are you currently on a GLP-1 protocol or program?

Please list any existing medical conditions.

Please list all current medications.

Please list any past surgeries or major injuries.

Do you have any food allergies? If so, please list them.

Have you been diagnosed with any cardiovascular or respiratory conditions? If so, please list them.

GLP-1 program details

What GLP-1 medication were you prescribed? (as written on your prescription)

When did you start the program? (month / year)

What is your current dose?

How often do you take it?

Who is your prescribing provider? (name / practice)

Has your prescribing provider been informed that you are starting a training program?

What side effects have you experienced? (e.g. nausea, fatigue, digestive changes)

How has your appetite or sense of fullness changed?

3. Physical fitness background

Have you previously worked with a trainer?

Describe your current physical activities or exercise routine.

What are your specific fitness or self-defense goals?

4. Lifestyle and habits

What is your occupation?

How many hours do you work per week?

Describe your typical daily activity level.

How many hours of sleep do you get per night?

Do you smoke or drink alcohol? If so, how much?

5. Exercise preferences and limitations

Which exercises or physical activities do you enjoy?

Which exercises or activities do you dislike or prefer to avoid?

Do you have any physical limitations or injuries that may affect exercise? If so, please describe them.

6. Nutrition and dietary habits

Describe your current eating habits.

Do you have any dietary goals or restrictions? If so, please describe them.

Would you be open to nutritional guidance?

Nutrition on GLP-1

How much protein do you eat each day? (if known)

How much water do you drink each day?

Which foods are hard for you to tolerate now?

Please list any vitamins or supplements you take.

7. Additional information

Is there anything else your trainer should know?

This form does not save your answers online. Preparing the questionnaire creates a downloadable copy and an email addressed to Mike for you to review and send.

Your questionnaire is ready.

Download a copy for your records, email the completed questionnaire to Mike, then continue to consultation times.

Email completed questionnaireContinue to consultation times