Inner Circle Members Questionnaire
Name
*
First
Last
Email
*
Why do you think you're not at your desired goal right now?
What is your occupation, and tell me about your role within that?
Tell me about your day to day schedule.
Be detailed in regards to your activity, (sitting or moving) and how busy your day is with work and home life.
Give me an example of your average daily nutrition.
Be detailed in regards to your breakfast, lunch, dinner and snacks.
What are your weekly step count totals for the last 3 weeks BEFORE you joined The Health Hub?
Get this total from your phone or watch step counter. Be exact, no guessing!
Are you hungry between meals? If yes, when is this? Between which meals?
What one habit do you wish you could stop and why you think you can't?
Example – Eating too much chocolate/biscuits every evening.
What good habits/actions do you struggle to stick to? Give me a recent example.
Example: I try to start going to the gym every morning but I last about a week or two.
What exercise, sports or activity do you enjoy?
What's the minimum amount of time and days you can realistically commit to exercising?
Do you have any injuries?
If there was one thing that you think will stop you from achieving your results what would it be?
What is your current weight in KG?
KG ONLY
Sex
Female
Male
Age range
18 – 29
30 – 59
60 – 74
Height (cm)
Centimetres only
What do you want to achieve with your weight?
Lose weight
Gain weight
Maintain weight
Occupational Activity Levels
*
Light
Moderate
Heavy
How active are you at work? Light would be sedentary desk job. Moderate might be teaching, hairdressing, on your feet all day. Heavy is building, warehouse type work, heavy lifting etc.
Non Occupational Activity Levels
Light
Moderate
Heavy
How active are you outside of work. Light is up to 3 days a week light exercise. Moderate is 2-5 moderate/hard exercise a week. Heavy is 6-7 days a week hard exercise.
What are your ideal weight and other health and fitness goals?
Have you tried to reach any of these goals before?
Yes
No
If yes, what success did you have?
If yes, what success did you have?
What problems did you encounter?
Can you think of any situation/people that may prevent you from achieving these goals?
When do you want to achieve these goals by?*
How motivated are you to achieve these goals?
1
2
3
4
5
6
7
8
9
10
Choose from the drop down – 1 is not at all, 10 is extremely motivated.
Want to learn more?
Check out these articles below
“It’s an instant failure when you look in the mirror…”
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Meet Anne, and hear her success story!
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Is your environment causing you to FAIL?
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How do I lose a few pounds?
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