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Challenge Group Questionnaire
The questionnaire below contains some personal questions. I ask these questions so I can really get a feel for who you are and what makes you tick. Please answer the following questions as honestly as possible…If you drink a 2 liter of Mountain Dew per day, don't tell me you have a soda during the day to keep you awake. If it ends up being 10 pgs long that’s fine too!
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Name
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First
Last
Phone Number
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Email
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Current Coach
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Current Fitness Activity Level
Are you doing any workouts currently? If so what kind of workouts and at what frequency?
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Do you have any physical limitations? (asthma, bad knees, bad wrists, etc)
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What are your most and least favorite workouts?
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Diet and Nutrition Assessment
Do you currently take any dietary supplements?
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Do you have any dietary restrictions?
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What beverages do you typically drink during the day?
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Water
Coffee
Coffee Drinks (Lattes, Cappuccino, etc)
Tea
Fruit Juice
Soda
Diet Soda
Energy Drinks
Health Shakes/Smoothies
Wine
Beer
Hard Liquor
Describe a typical day of eating? How many meals? Do you eat breakfast? Do you snack?
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How many times a week do you eat out at restaurants?
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Do you track your daily calorie intake?
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Yes
No
If you have tracked calories, how do you feel it has helped or hurt your nutrition diet?
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Environment and Support System
Do you have anyone in your household that will be making the same commitment to exercise and nutrition while you participate in this group?
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Yes
No
If you live with others that aren't going to participate, on a scale of 1-10 how supportive are they of your decision to eat better and workout regularly?
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Do you have anyone else outside of the group that you are joining that will provide support and encouragement?
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Do you have food/candy sitting out on counters at home or work?
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Goals
What is the #1 reason for you wanting to be a part of this group?
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Improve Health
Lose Weight
Increase Strength
Gain Muscle Mass
Lose Body Fat
More Energy
Be an example for people close to you
Perform better at a specific sport
Help Others
Learn to Eat Better
Something Else, Explain Below
Why is that your #1 reason?
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Are you willing to make sacrifices with your time, your social life, and even your sleep to reach that goal?
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Yes
No
Maybe
What do you foresee being your biggest challenges during this group?
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Exercise
Diet
Time Management
Meal Planning
Posting Daily Online
Support
Staying Focused on Weekends
Nothing, I'm Ready to Go
Other
Other
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Additional Comments or Concerns
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Would you like to receive The Cook & The Coach Newsletter? It will contain additional recipes, extra fitness motivation along with additional information that will help you on your fitness journey.
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Yes, I'd like to receive the newsletter.
No, I do not want to receive the newsletter
Thanks for taking the time to fill this out. Having a little bit more information about where you are coming from will help us better work with you while you are part of this group. You can expect to hear back from us shortly with any questions we may have and a game plan for getting you started right.
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