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ABOUT JERRY
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My Account
ENQUIRE
PORTFOLIO
ABOUT JERRY
Building lean, muscular body's for the everyday Aussie bloke!
ALPHA CHICKS
BLOG
SHOP
PROGRAMS
PACKAGES
QUESTIONNAIRE
Name
*
First Name
Last Name
Email
*
Mobile Number
*
Country
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Current Weight in Kilos
*
Height
*
What are your Physique + Health Goals?
*
How would you describe your training experience?
*
Experienced with structured training
Have trained on and off over the years
New to structured training
How would you describe your level in the gym?
*
Experienced
Competent
Novice
Where will you be training?
*
Gym
Home
If training at home, what equipment do you have?
What does your current exercise regime consist of?
*
Is there any reason why you're not able to do certain exercises/movements?
*
Do you have any injuries or recent surgeries I should be aware of?
*
Do you train with a Garmin or Smart Watch
*
Yes
No
If yes, what is your Garmin account name/link (so I can connect with you):
Would you consider investing in a Garmin for achieving optimal performance and performance monitoring and tracking?
Yes
No
Maybe
Your current VO2 Max if you know it
Would you like information on getting a DEXA body scan done to measure your starting body fat?
*
YES
NO
Dietary Preference
*
No Preference
Omnivore
Pescatarian
Vegetarian
Vegan
Ketogenic
Carnivore
Dairy Free
Gluten Free
Religious Specific
Other (expand below)
What are your current eating habits. Please describe a typical day on your current diet?
*
Do you have any issues in the following areas?
*
Digestion/Gastric
Headaches/Migraines
Food Intollerances
Insomnia
Depression/Anxiety
Constipation/Diahorrea
Other
None
Expand on any health conditions or illnesses
*
List any current medications
*
How much water do you drink a day?
*
How much coffee do you drink per day?
*
Do you smoke?
*
YES
NO
Do you drink alcohol regularly?
*
YES
NO
What time do you usually wake in the morning?
*
What time do you usually sleep at night?
*
What is your usual schedule on a weekday?
*
What is your usual schedule on the weekend?
*
What areas do you struggle with the most?
*
Motivation
Sticking to an eating plan
Food temptations
Lack of support
Mindset
Understanding exercises
Health condition
Lack of knowledge
No relevant struggles
What top 3 goals do you want to achieve by the end of your 3 months program?
*
Any additional information you would like to share with me:
