Cart
0
Home Page
Online Training
SHOP
Cart
0
Home Page
Create A New Lifestyle Engineered by You
Online Training
SHOP
Lawless Health Triage Questionnaire
SECTION 1
What do you want? In general, what are your goals?
*
Check all that apply
Lose weight/fat
Gain weight
Maintain weight
Build muscle
Get Stronger
Improve physical fitness
Move better
Look better
Feel better
Have more energy
Improve athletic performance
Please list all concerns about your health, eating habits, fitness and body.
*
Out of all of the above concerns, which ones feel most important/urgent and why?
*
When would you like to achieve these by?
*
What do you want to change? Have you tried anything in the past to change your habits, health, eating or your body? If so, what?
*
Which of those things worked well?
Which of those things didn’t work well?
*
How specifically, would you like your habits, health, eating or body to be different?
*
Have you already made changes to your habits, health, eating, body recently? If so, what?
*
If you were to consider making further changes to your habits, your health, your eating or body, what might those be?
What has prevented you from making changes up until now?
SECTION 2
From a scale of 1 to 10, how would you rank your eating/nutrition
*
Horrible 1 2 3 4 5 6 7 8 9 10 Awesome (Tick one box)
1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
Biggest food craving?
*
Biggest struggle with staying on top of a “healthy” diet?
*
Are you regularly active in sport and exercise?
*
(Tick one box)
Yes
No
If so, how many hours per week?
*
(Tick one box)
0
< 2
2 - 3
4 - 5
> 5
If yes, what types of sport/exercise do you typically do?
*
Approximatelyhow many hours a week do you do other types of physical activity? (Housework, walking, home repairs, moving around etc.)
*
(Tick one box)
0
< 5
5 - 9
10 - 14
15 +
What type of physical activity/movement does this include?
*
SECTION 3
Who’s around you? Who lives with you?
*
Do you have children? If yes, how many and their ages?
Who does most of the grocery shopping in your household?
*
Who does most of the cooking?
*
Who decides on most of the menu/meal types in your household?
*
Right now, how much do the people around you support health, fitness and behavior change?
*
SECTION 4 - How are you spending your time? In an average week, how many hours do you spend…
a. In paid employment b. Travelling and/or commuting c. Taking care of others? d, Doing other unpaid work? e. Volunteering
*
b. Travelling and/or commuting
*
c. Taking care of others?
*
d, Doing other unpaid work?
*
e. Volunteering
*
In total, how many hours a week do you spend doing these activities?
*
What is your current occupation?
Do you have any travel (business or pleasure) planned over the next 8 weeks?
*
If yes, please state if you will you have access to a gym or area to do physical activity
On a scale of 1 - 10, how do you feel about your schedule, time use and overall busy-ness?
*
Packed/Busy 1 2 3 4 5 6 7 8 9 10 Perfectly calm/Relaxed (Tick one box)
1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
What day(s) would work best for you for training and improving your lifestyle?
*
Pick days that works best for your schedule
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
On average, how many hours’ sleep do you get per night?
*
Given the demands of your life and day, what is your typical stress level?
*
No stress 1 2 3 4 5 6 7 8 9 10 Extreme Stress (Tick one box)
1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
How do you cope with this stress?
*
How ready, willing and able are you to change? How READY are you to change your behaviors and habits?
*
Not at all 1 2 3 4 5 6 7 8 9 10 Completely (Tick one box)
1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
How WILLING are you to change your behaviors and habits?
*
Not at all 1 2 3 4 5 6 7 8 9 10 Completely (Tick one box)
1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
How ABLE are you to change your behaviors and habits?
*
Not at all 1 2 3 4 5 6 7 8 9 10 Completely (Tick one box)
1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
Which of the following will you feel confortable with showcasing on Lawless social platforms
*
Check all that apply
Progress photo
Body stats
Personal Best
Acheivements
Conversation Snippets (Example: Feedback, Accountability)
Clients Name
Clients Name
*
Please read : RELEASE AND WAIVER OF LIABILITY AND INDEMNITY #17 at bottom of the document before submitting)
Date
*
MM
DD
YYYY
Thank you!
