Core's Roadmap Questionnaire

Roadmap Questionnaire
Today's Date

Month Day Year
Date
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Age *
years
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Email *
example@example.com
Preferred form of contact? (Please check all that apply) *

Phone call Email Text Message
What do you do for a living? *
Whats the activity level at your job?

none(seated only) Moderate (light activity such as walking) High (heavy labor, very active)
Work Hours *

I work regular hours every week I work irregular hours I am in complete control of my schedule
Have you EVER suffered from or been diagnosed with any of the following (check all that apply) *

High Blood Pressure Pulmonary Disesase Cancer Seizure Allergies Hernia Joint Pain/Injury/Condition High Cholesterol Difficulty breathing Vascular Disease Recent illness Diabetes Tremors Lower Back Pain Upper Back/Neck Pain Shoulder Pain Knee Pain Ankle Pain Unusual Fatigue Boren Boen Heart Attack, Stroke, or Arrythmia Asthma None of the above
Any other injuries/concerns? *
Please list any surgeries (dates/types)
We don't need to know about routine procedures like wisdom teeth, tonsils, ... But if you've had surgery that was due to a complication, injury, or event that impacted your ability to take part in your daily activities of living, please list them out.
Do you have family history of your father or other male first-degree relative suffering an MI or sudden death before the age of 55? *

Yes No
Are you a current cigarette smoker? *

Yes No
Has your doctor ever said you have a hart condition and that you should only do physical activity recommenced by your doctor? *

Yes No
Do you feel pain in your chest when you do physical activity? *

Yes No
In the past month, have you had chest pain when you were not doing physical activity? *

Yes No
Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes No
Do you have a bone or joint problem that can be made worse by a change in your physical activity? *

Yes No
Is your doctor currently prescribing drugs (i.e. water pills_ for your blood pressure or heart condition? *

Yes No
Do you know of any other reason why you should not do physical activity? *

Yes No
Are you taking any medications? *

Yes No
If you are on any medications, please list them.
If my health should change so that I could answer yes to any of the above yes or no questions and medication during our time working together, I understand that I am responsible for informing Core Strength & Performance, LLC *

Yes No
On average, how many hours of sleep do you get each night? *
Do you sleep through the night? *

Yes No
Do you wake up feeling rested/energized? *

Yes No
Do you struggle with energy throughout the day? *

Yes No
How would you describe your overall stress levels? *

Low Moderate High
How do you fell like you're currently doing with your nutrition? *

Great Could be better Terrible Other
Have you ever worked with a trainer or done instructor led fitness before? *

Yes No
If yes, what have you done? (1-on-1 personal training, Small group Personal Training, Crossfit, Spin, Orange Theory, Yoga,...) *
What have you been doing most recently to try and accomplish your health/fitness/performanCe goals? *
Tell us a little about your like/dislikes and whats worked for you in the past/maybe not worked so much in the past *
On a scale of 1-10, how do you feel about pushing through pain/discomfort? 1= stop at first sign of anything feeling at all off". 10= "No pain, no gain!" *
Anything you'd like to add to expand on the number you picked above? *
How important is building muscle, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is gaining strength, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is dropping weight/body fat, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is cardiovascular endurance, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is sweating during a workout, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is your overall health to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is feeling better, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is looking better, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is resistance to injury, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is increasing energy, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is using proper exercise form, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
How important is variety, to you, on a scale of 1-10 (not important - extremely important) *

1 2 3 4 5 6 7 8 9 10
If we were meeting one year form today- and you were to look back over the last year to today- what has to have happened during that period for you to feel happy about your progress? Feel free to write a book here---the more detailed the better! *
If we could figure this out, what value will this bring to your life? what does will it open? How will your life be better? *
How will we know we are track (what can we measure along the way?) *
How would your best friend describe you? *
Emergency contact (name, relationship, phone number) *
ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE THE ABOVE INFORMATION IS CORRECT *

Yes No
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