JOIN US Please contact us for availability. NAME EMAIL * PHONE * MESSAGE Thank you! To get your journey started please fill out the forms below; BODY IQ QUESTIONNAIRE BODY IQ The Body IQ questionnaire explores the different areas of your lifestyle that influence your health, body shape and daily performance. It measures the likelihood of you achieving (or not achieving) your health, energy, weight management and performance goals based on the 6 critical pillars of women’s health. For each of the statements below choose the response that best characterises how you feel about the statement. NAME I often bring work home at night 0 - Never 1 - Sometimes 2 - Usually 3 - Always I check emails or social media accounts at night in bed, and first thing in the morning 0 - Never 1 - Sometimes 2 - Usually 3 - Always I feel like there are not enough hours in the day to do all the things I have to 0 - Never 1 - Sometimes 2 - Usually 3 - Always In order to get the job done it is easier to do it myself 0 - Never 1 - Sometimes 2 - Usually 3 - Always I find it difficult to relax 0 - Never 1 - Sometimes 2 - Usually 3 - Always I don’t find it easy to let trivial things or annoyances slide 0 - Never 1 - Sometimes 2 - Usually 3 - Always I experience unexplained mood swings, difficulty making decisions, and can be forgetful 0 - Never 1 - Sometimes 2 - Usually 3 - Always I don't feel as if I have support from my family, friends and loved ones when I feel scared, angry, upset or anxious 0 - Never 1 - Sometimes 2 - Usually 3 - Always I take prescribed medications that are related to stress or a psychological disorder 0 - Never 1 - Sometimes 2 - Usually 3 - Always I get sick often - I seem to catch colds and illnesses easily 0 - Never 1 - Sometimes 2 - Usually 3 - Always SECTION 2 I have trouble getting to sleep at night 0 - Never 1 - Sometimes 2 - Usually 3 - Always I wake up during the night and I can be a light sleeper 0 - Never 1 - Sometimes 2 - Usually 3 - Always On average I get 6 hours of sleep per night or less 0 - Never 1 - Sometimes 2 - Usually 3 - Always I fall asleep on the couch in the early evening but then find I have a second wind so stay up late (e.g. after 10pm) 0 - Never 1 - Sometimes 2 - Usually 3 - Always I hit snooze on my alarm multiple times in the morning before getting up 0 - Never 1 - Sometimes 2 - Usually 3 - Always I take medication to get a better night sleep I drink coffee to help me through the day (more than 3 cups) 0 - Never 1 - Sometimes 2 - Usually 3 - Always I don’t seem to have a stable bed time; I go to bed at different times throughout the week and weekend 0 - Never 1 - Sometimes 2 - Usually 3 - Always I go to bed after 10 pm 0 - Never 1 - Sometimes 2 - Usually 3 - Always I wake up feeling tired, and as if I need more sleep 0 - Never 1 - Sometimes 2 - Usually 3 - Always SECTION 3 I have a job that is requires me to be seated 0 - Never 1 - Sometimes 2 - Usually 3 - Always I sit for long periods of time without standing for a break (e.g. more than 60 minutes) 0 - Never 1 - Sometimes 2 - Usually 3 - Always On an average day I would struggle to walk at least 10,000 steps (or 60 mins of accumulated walking) 0 - Never 1 - Sometimes 2 - Usually 3 - Always I sit whilst going to and from work each day (e.g. bus, car, train) 0 - Never 1 - Sometimes 2 - Usually 3 - Always Overall, I am not pleased with the condition of my body 0 - Never 1 - Sometimes 2 - Usually 3 - Always I watch TV or am on a device more than 2 hours of per day whilst sitting (outside of work time) 0 - Never 1 - Sometimes 2 - Usually 3 - Always I am not satisfied with my current energy levels 0 - Never 1 - Sometimes 2 - Usually 3 - Always When I’m really tired, I go to the gym or participate in exercise even though I would benefit from doing something less intense 0 - Never 1 - Sometimes 2 - Usually 3 - Always I feel as if I have to do certain exercises to ‘burn calories’ And burn a certain number of calories in my workout 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have work related injuries such as RSI, Overuse Syndrome, sore neck, shoulders +/or lower back issues 0 - Never 1 - Sometimes 2 - Usually 3 - Always SECTION 4 After eating I experience abdominal bloating, pain or discomfort 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have irregular stool movements 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have gas and I burp or belch after meals 0 - Never 1 - Sometimes 2 - Usually 3 - Always I find it difficult to drink 5 glasses of water a day (not including coffee/flavoured drinks) 0 - Never 1 - Sometimes 2 - Usually 3 - Always I consume diet drinks or sugar free products (such as Equal) at least once a day 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have known food allergies 0 - Never 1 - Sometimes 2 - Usually 3 - Always There are days where I do not eat any vegetables at all I eat out at least 5 times per week (including breakfast, lunch, snacks and dinner) 0 - Never 1 - Sometimes 2 - Usually 3 - Always I eat each meal whilst doing something e.g. at my desk, on my phone, watching TV 0 - Never 1 - Sometimes 2 - Usually 3 - Always On an average week I have less alcohol-free days then days with alcohol 0 - Never 1 - Sometimes 2 - Usually 3 - Always SECTION 5 I have dieted or have been on some form of controlled eating plan more than 3 times in my life 0 - Never 1 - Sometimes 2 - Usually 3 - Always I count calories, weigh food and/or track my intake (such as My Fitness Pal) 0 - Never 1 - Sometimes 2 - Usually 3 - Always I often eat or drink when I am tired, stressed, upset, bored or lonely 0 - Never 1 - Sometimes 2 - Usually 3 - Always I get stressed or concerned when I have to go out for dinner, and I don’t know what is on the menu 0 - Never 1 - Sometimes 2 - Usually 3 - Always I am not happy with my body shape/size right now and I am concerned about it 0 - Never 1 - Sometimes 2 - Usually 3 - Always I feel that I give way too much time and thought to food 0 - Never 1 - Sometimes 2 - Usually 3 - Always I am preoccupied with having fat on my body 0 - Never 1 - Sometimes 2 - Usually 3 - Always I find it difficult to enjoy a fabulous meal out or indulge in treats without ‘blowing it’ and without feeling guilty or disappointed 0 - Never 1 - Sometimes 2 - Usually 3 - Always I feel as if I can’t rely on my body’s natural hunger cues 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have used or are currently using laxatives, diet pills or diuretics to control my weight. 0 - Never 1 - Sometimes 2 - Usually 3 - Always SECTION 6 I find it difficult to look at myself naked in the mirror 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have many negative thoughts about my body 0 - Never 1 - Sometimes 2 - Usually 3 - Always I spend a lot of time comparing myself and my body to others – whether that is in real life or on social media 0 - Never 1 - Sometimes 2 - Usually 3 - Always I avoid clothes shopping because I don’t like seeing myself in the changing rooms 0 - Never 1 - Sometimes 2 - Usually 3 - Always I get annoyed or frustrated at myself for not having enough ‘motivation ‘or ‘willpower 0 - Never 1 - Sometimes 2 - Usually 3 - Always I avoid participating in certain activities or going to the gym because I am worried about what others will think of me 0 - Never 1 - Sometimes 2 - Usually 3 - Always If I was asked by a stranger to list my top 3 favourite parts of my body I would struggle to answer them 0 - Never 1 - Sometimes 2 - Usually 3 - Always I often feel bad about myself because I don’t like my body 0 - Never 1 - Sometimes 2 - Usually 3 - Always On many occasions I wish for my body to look different 0 - Never 1 - Sometimes 2 - Usually 3 - Always I believe that I will only be happy when I have lost my weight or achieved my goal look 0 - Never 1 - Sometimes 2 - Usually 3 - Always SECTION 7 I have been able to laugh and see the funny side of things 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have looked forward with enjoyment to things 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have blamed myself unnecessarily when things go wrong 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have been anxious or worried for no good reason 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have felt scared or panicky for no good reason 0 - Never 1 - Sometimes 2 - Usually 3 - Always Things have been getting on top of me 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have been so unhappy that I have had difficulty sleeping 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have felt sad or miserable 0 - Never 1 - Sometimes 2 - Usually 3 - Always I have been so unhappy that I have been crying 0 - Never 1 - Sometimes 2 - Usually 3 - Always The thought of harming myself has occurred to me 0 - Never 1 - Sometimes 2 - Usually 3 - Always Thank you! READINESS QUESTIONNAIRE PRE-ACTIVITY READINESS Name First Name Last Name Address Mobile Phone Email D.O.B Occupation Emergency Contact Name Emergency Contact Phone Number EXERCISE HISTORY Are you currently exercising? If YES, what? How long (months/years)? How many times per week? MEDICAL BACKGROUND Do any of the following medical or physical conditions apply to you? Heart Disease Stroke Raised Cholesterol High Blood Pressure Diabetes Are you male over 35 or female over 45 and NOT used to regular vigorous exercise? Are you on prescription medication? If yes, please describe Have you been hospitalised recently? Have you given birth in the last six weeks? Are you pregnant? Any heart condition Stroke, Dizziness or Fainting Pain in Chest, Raised Cholesterol/Triglycerides. High Blood Pressure > 140/90 Diabetes Arthritis Asthma Epilepsy Do you smoke? Are there any injuries or restrictions that may affect your participation in exercise? If yes, please describe Are there any other conditions which may be reason to modify your exercise program? If yes, please describe If you answered yes to any of the above conditions, have you been cleared to exercise by an allied Health professional? Does this person require referral to an allied health professional for medical clearance before commencing a physical activity program? Yes No FEMALE SPECIFIC QUESTIONS Do you menstruate on a regular basis? How long is a typical ‘cycle’ Do you currently have, or have had issues with your menstrual cycle e.g. irregular cycles, missing cycles (and not pregnant), PMS? At what age did you begin menses? Have you ever been diagnosed or told you have PCOS, endometriosis or other something similar? Have you had children? If so, did you have a vaginal delivery or C-Section? Who did you seek post-birth treatment and clearance from? Where there any complications during your pregnancy or birth? Do you ever leak or pee a little when you cough, pick something up, jump, run or do something similar? Have you ever had a surgery for Prolapse? Do you ever experience pain in the lower abdomen, pelvis or lower back? Do you think you are pre-menopausal or going through menopause? INTENTIONS What results/goals do you want from training? I need to get fitter I need to look my absolute best I need more muscle tone I want fat loss I need to build muscle I need to get stronger I need more energy I have a specific sporting goal I want to feel confident about my body I need to rehabilitate part of my body Other: Why is it important to you to achieve these goals? When would you like to achieve your goal/s by? Are there any factors that may prevent you from achieving these goals? (e.g. work, family, time, money) On a scale from 1 to 10, how committed are you to achieving your goal/s? LIFESTYLE Do you ever feel weak, fatigued, or sluggish? Yes No How many meals do you typically eat each day? Are you consciously aware of the food you eat? Yes No How many meals do you eat out each week? Do you crave sugary foods? Yes No Do you need several cups of coffee to keep you going throughout the day? Yes No How many hours quality sleep do you get per night? On a scale from 1 to 10, how stressed do you feel daily? Thank you!
