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Healthworks RESULTS Questionnaire

This questionnaire is for clients who have registered for the 12 Week Results Program.  Your answers will help your personal Results Coach design a program based on your goals and lifestyle.

If you have not yet signed up for the 12 Week Results Program, what are you waiting for?  Ask your Personal Trainer today or fill out our online inquiry form and we will start the registration process for you.

Please answer every question/statement:

Membership ID #                
Club:
Back Bay   Brookline
Cambridge  Chestnut Hill
Salem  
Name
 Have you already purchased a RESULTS package?  Yes   No
Email Address
Age
Height
 Weight
 Ideal Weight
 
My goal is:
Lose 1 lb. a week
Lose 2 lbs. a week
Gain 1 lb. a week
Gain 2 lbs. a week
Maintain Weight
 
Fitness Goal:
Heart Healthy
Weight Management
Cardiovascular Fitness
Strength / Tone / Anaerobic
 
Activity Level:
Sedentary - little or no exercise
Lightly Active - 1-3x/week
Moderately Active - 4-5x/week
Very Active - exercise/sports 4-5x
Extremely Active - exercise/sports/job
 
Weight Management
I would  like to start managing my weight:
To improve the way I look
To improve my confidence
To improve my energy level
To feel better in my clothes
For health reasons
My doctor suggested it
My family suggested it
I have an event coming up
 

My motivation to start losing weight is:
Very High  Moderate  Low
 
My knowledge about how to lose weight and keep it off is:
I know what it takes
I am pretty sure I know
I don't know where to start
 
The following statement describes my weight management:
I have tried every diet known
I have been battling weight for many years
I recently gained weight and need help losing 5-10 pounds
My doctor has recommended that I lose weight
Other:
 
Eating Habits

When trying to lose weight, I need to improve:		  
Serving Sizes Regular Meals Dealing with Cravings
Making better choices Emotional Eating Feeling hungry
 
I plan my meals and snacks:
Never Sometimes (1-3x/wk) Often (4+ times/week)
     
I often snack when feeling down, stressed, angry, bored, etc.
Never Sometimes (1-3x/wk) Often (4+ times/week)
 
I drink water:
Never Sometimes (1-3x/wk) Often (4+ times/DAY)
     
I eat fruit and vegetables:
Never Sometimes (1-3x/wk) Often (4+ times/DAY)
 
When eating bread and cereals, I eat whole grains, whole wheat. rye, oatmeal or multigrain:
Never Sometimes (1-3x/wk) Always
     
When eating protein, I eat lean mean, without skin:
Never Sometimes (1-3x/wk) Always
 
I eat food from take-out or fast food (Starbucks, Pizza, Chinese...)
Never Sometimes (1-3 x/wk) Often (4+ times/week)
     
Activity Habits
 
During a normal day, I spend hours sitting.  This includes time spent driving, sitting at a desk, using a computer, watching television, etc.
     
Currently, I am doing 30+ minutes of cardiovascular exercise:
Never Sometimes (1-3x/wk) Often (4+/wk)
     
The reason that I do not get as much physical activity as I would like is:
Lack of time Lack of Motivation Injury/health problems
No reason, I get plenty of exercise
 
On average, how many hours of sleep do you get per night:
7 or more hours 5 to 6 hours Less than 5 hours
 


   

We respect your privacy. Under no circumstances will Healthworks use your personal information for any purpose other than to help design your RESULTS program.