Health Questionnaire - Lighthouse Wellness Coach

This comprehensive questionnaire helps us create a personalized fitness and nutrition plan tailored to your specific needs and goals. All information is kept confidential.

Fields marked with an asterisk (*) are required.

Personal Information

Full Name

Phone Number

Age

Gender

Male

Female

Other

Height (in inches)

Example: 5'8" = 68 inches

Weight (in pounds)

Health History

Do you have any medical conditions?

Yes

Please list all medical conditions:

Include conditions such as diabetes, hypertension, heart disease, etc.

Do you have any chronic injuries?

Yes

Please describe your injuries:

Include location, severity, and how long you've had the injury.

Do you have any allergies or food sensitivities?

Yes

Please list all allergies and food sensitivities:

Are you currently taking any medications?

Yes

Please list all medications:

Include name, dosage, and reason for taking.

Fitness Background

Current Activity Level

Exercise History

Describe your past experience with exercise and any specific activities you enjoy.

What types of exercise do you currently do?

Cardiovascular (running, cycling, etc.)

Strength Training

Flexibility/Mobility (yoga, stretching, etc.)

Sports

None currently

How many days per week can you commit to exercise?

Average duration of exercise session (in minutes)

Goals & Expectations

What is your primary fitness goal?

What event are you training for?

Secondary goals (if any):

Timeframe for achieving your primary goal:

On a scale of 1-10, how motivated are you to achieve your goals?

What barriers might prevent you from achieving your goals?

Examples: time constraints, work schedule, family commitments, etc.

Which of our packages are you most interested in?

Any additional information you'd like to share:

Privacy Notice: The information you provide will be used solely for the purpose of creating your personalized fitness and nutrition plans. We will never share your personal information with third parties.

Thank you for completing the health questionnaire!

Your information has been submitted successfully.

We'll review your responses and be in touch with you shortly to discuss your personalized fitness and nutrition plan.

Lighthouse Wellness Coach

Health & Fitness Questionnaire

Personal Information

Health History

Fitness Background

Nutrition

Goals & Expectations

Thank you for completing the health questionnaire!