LIFESTYLE QUESTIONAIRE

Section 1: General Information

Full Name: ___________________________________ Age: ________  Height: ________  Weight (optional): ________ Phone: ___________________  Email: ___________________ Occupation: ___________________________________ Emergency Contact Name & Number: ___________________________

Section 2: Health & Wellness History

1. Do you have any diagnosed medical conditions? ☐ No ☐ Yes – Please specify: _____________________________________

2. Are you currently taking any medications or supplements? ☐ No ☐ Yes – List: _____________________________________________

3. Have you had any surgeries or injuries that may impact training? ☐ No ☐ Yes – Explain: ___________________________________________

4. Do you currently work with a healthcare practitioner (e.g., doctor, physio, therapist)? ☐ No ☐ Yes – Who and for what purpose: ___________________________

5. Do you experience any of the following? (Check all that apply) ☐ Fatigue ☐ Stress ☐ Poor sleep ☐ Anxiety ☐ Depression ☐ Digestive issues ☐ Menstrual irregularities ☐ Perimenopause/Menopause

Section 3: Fitness & Movement

1. What’s your current activity level? ☐ Sedentary ☐ Light activity ☐ Moderate (3–4x/week) ☐ High (5–6x/week)

2. What types of movement do you enjoy? ☐ Walking ☐ Lifting weights ☐ Yoga ☐ HIIT ☐ Running ☐ Dancing ☐ Outdoor activities ☐ Other: ____________________________

3. How many days per week would you like to train? ___________

4. What time of day do you feel most energized to work out? ___________

5. Do you currently follow any fitness or nutrition program? ☐ No ☐ Yes – Please describe: _________________________________

Section 4: Lifestyle & Nutrition

1. How many hours of sleep do you get on average? ______ /night

2. Do you wake feeling rested? ☐ Yes ☐ No

3. How would you rate your stress level? ☐ Low ☐ Moderate ☐ High ☐ Overwhelmed

4. How many meals per day do you typically eat? ___________

5. Do you drink: ☐ Coffee – Cups/day: ____ ☐ Water – Cups/day: ____ ☐ Alcohol – Drinks/week: ____ ☐ Energy drinks or soda – Frequency: _________

6. Do you follow a specific way of eating (vegan, low-carb, etc)? ☐ No ☐ Yes – Please explain: _________________________________

Section 5: Mindset & Goals

1. What are your top 3 goals for working together?

1. What has held you back in the past from reaching these goals?

2. What motivates you most? ☐ Health ☐ Confidence ☐ Strength ☐ Appearance ☐ Mental clarity ☐ Energy ☐ Longevity ☐ Other: ___________

3. On a scale of 1–10, how ready are you to make lifestyle changes? ___/10

4. How can we best support you in this process?

Signature & Consent

By submitting this form, I affirm that the information provided is true to the best of my knowledge. I consent to the use of this information for personalized program development and coaching by House of GlamRock.

Client Signature: _________________________  Date: ___________