TITUS FITNESS PERFORMANCEPAR-Q INTAKE FORM Name * First Name Last Name Are you married? * Yes No Do you have children? * Yes No Do you have strong relationships and community outside of family and work? Please go into some detail. * Do you feel that your goals are supported by your respective family, friends, and community? Please go into some detail. * How would you classify your personality? * Introverted Extroverted Situational Please explain a little about your personality. What is your profession? * How many hours do your work within the average week? * Below 20 21-30 31-40 41+ How would you rate your job fulfillment? * Please add some detail about your job satisfaction. * How many hours do you spend outside on an average weekday? * Below 1 1-2 3-4 5+ Do you spend over 10 hours outside on an average weekend? * Yes No Sometimes Please explain a little about your weekend activities. * How many hours do you sleep in an average night? * Below 4 4-6 6-8 8+ How would you rate your sleep quality? * If your sleep is on the poor side, please let me know a little about what's going on. Would you consider yourself as someone who is overly stressed? * Yes No Maybe How would you rate your average stress level? * Please list your current stressors * Family Work Finances Social Obligations Health Relationships School Body Image Sports Performance General Environment Other Please explain a little more about what is stressful. * How many steps do you take in an average day? * Below 5K (below 2 miles) 5k-10k (2-4 miles) 10k-15k (4-6 miles) 15k+ (6+ miles) Not sure How would you rate your overall energy? * How would you rate your libido? * Do you have regular bowel movements? * Yes No Sometimes Do you have frequent diarrhea and/or constipation? * Yes No If you answered yes, please explain what you experience more and how often. How many meals do you eat in an average day? * 1 2 3 4+ Do you have any dietary restrictions and/or follow any any specific diets? * Yes No If yes, please explain more about your diet. How many nights a week do you eat out in an average week? * 1 2 3 4+ Do you track you calories? * Yes No Sometimes How many calories do you ingest (eat and drink) in an average day? * Below 1000 1000-1500 1500-2000 2000-2500 2500-3000 3000+ How many ounces of water do you drink in an average day? * 0-20 21-40 41-60 61-80 80+ How many caffeinated drinks do you drink in an average day? * 1 2 3 4+ None How many nights a week do you drink alcohol on average? 1-2 3-4 5+ None Do you currently take any supplements? Yes No If yes, please list them. Do you currently take any prescription drugs? * Yes No If yes, please list them. Do you currently use any non-prescription drugs? * Yes No Do you see a physician regularly? * Yes No Do you schedule an annual physical? Yes No Do you feel comfortable discussing your physical health with your physician? * Yes No If no, please explain. Do you ever experience dizziness or a loss of balance? * Yes No If yes, please explain. Do you have any previous or current medical issues that may effect your training? * Yes No If yes, please explain. When was the last time you scheduled blood work? * Over a year ago Within this year Never Thank you! I truly appreciate your business. I am dedicated to helping you achieve what you set out to do.
