Premium Member Questionnaire – Resubmission


    Premium Member Questionnaire

    Lastname:

    Firstname

    Phone #:

    Email Address:

    Date of Birth:

    Sex:
    MF

    Height:

    Weight:

    Do you have any food allergies?

    If Yes, Explain: (Nuts, Shell fish, Lactose intolerant, etc.)

    Do you have Diabetes?

    If you answered Yes, indicate type:

    Do you have any other blood sugar disorders?

    If Yes, Explain:(Hypo/Hyperglycemia, etc.)

    Have you been diagnosed with any heart disease, high blood pressure, high cholesterol?

    If Yes, Explain:

    Have you been diagnosed with any thyroid health issues?

    If Yes, Explain:

    Are you currently on any medications?

    If Yes, List:

    Have you been diagnosed with any other medical conditions that might affect or be affected by your diet?

    If Yes, Explain:

    Please keep a food journal for the next 3 days. Don’t change your diet at all. Write down everything you consume, including drinks, snacks, and condiments. Record serving sizes. Be as specific as possible. You will email this list to your coach. We will discuss this together, and use it as a baseline to start constructively changing your eating habits.


    That completes part 1 of the Questionnaire

    Next, you will be asked some questions that will help us design a program tailored to your goals.


    Program Builder Questionnaire

    Would you currently describe yourself as:
    UnderweightLean/AthleticMediumOverweightObese

    Breifly describe your experience with strength training:

    How recently have you been practicing that experience?
    DailyWeeklyMonthlyPeriodicallyNever

    Are you "in shape" for you right now?

    Describe your fitness level as it relates to your previous best level of fitness

    Breifly describe your experience with conditioning training

    How recently have you been practicing that experience?
    DailyWeeklyMonthlyPeriodicallyNever

    Are you in good cardio shape right now?

    Explain your participation in any sports or very active hobbies:

    Explain your participation in any sports as a youth:

    What are your goals now? What is most important to achieve? Body composition changes? Improvement in a specific sport? General mobility? A fun challenge? Improved health? You name it. Please describe all of your goals in detail.

    What equipment do you have access to for your training? List all.

    How much time will you commit to training? Be specific.

    How many days per week?

    How much time per session?

    What days can you train? (Check all that apply)
    SundayMondayTuesdayWednesdayThursdayFridaySaturday

    Can you perform an "overhead-squat"? [Click for video]

    If No, where/how do you struggle during the motion?

    List anything you would like me to consider while designing your program. (Are you limited in any way by tightness, weakness, previous injuries, etc.?)

    List all previous injuries here:

    JoeToProAthlete.com recommends that you speak to your doctor before beginning any exercise program. Are you 100% ready and cleared for exercise? Be sure. We also have a quick questionnaire here to get you started. Read through it before you submit your program builder.

    Do you have / ever been diagnosed with:

  • Heart condition
  • Diabetes
  • Asthma
  • Osteoporosis
  • Chest pain with exercise
  • Fainting or dizzy spells with exercise
  • Recent surgeries
  • High blood pressure
  • High cholesterol
  • Seizures
  • Any other conditions that might limit you when beginning an exercise program
  • Be sure to check with you doctor before beginning any exercise program


    That completes the Program Builder Questionnaire

    I have read the entire contents of this questionnaire and understand the risks. The information I have provided is accurate and correct to the best of my knowledge.

    I Agree