Pirelli Fitness Questionaire
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Full Name
*
First
Last
Height in Inches
*
Please Select
54
55
56
57
58
59
60
61
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65
66
67
68
69
70
71
72
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85
Weight in LBS
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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2007
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
SELECT
MALE
FEMALE
Work Activity Level
*
Please Select
Select one
Sedentary: Spend most of the day sitting (e.g. bank teller, desk job)
Lightly Active: Spend a good part of the day on your feet (e.g. teacher, salesman)
Active: Spend a good part of the day doing some physical activity (e.g. waitress, mailman)
Very Active: Spend most of the day doing heavy physical activity (e.g. bike messenger, carpenter)
Which closely describes your current work activity
Exercise Activity Level
*
Please Select
SELECT
Little / No Exercise
3 times a week
4 times a week
5 times a week
6 times a week
Daily
How many days can you commit to exercising
Alcohol Consumption
*
Please Select
SELECT
None
Socially (2 drinks a week)
3-5 Drinks a week
5-10 Drinks a week
10+ Drinks a week
What is your goal
*
Please Select
Cut bodyfat
lose 1 pound a week
lose 2 pounds a week
healthy living
bulk or build muscle
not sure need assistance
Time allotted for exercise per day
*
Please Select
15 mins
30 mins
45 mins
60 mins
60+ mins
Cardio / Weight LIfting
Do you belong to a GYM?
*
Please Select
YES
NO
Do you prefer Free weights or Machines
*
Please Select
Machines
Freeweights
Both / Doesn't matter
Do you want to workout at home?
*
Please Select
YES
NO
Do you have a treadmill?
*
Please Select
YES
NO
Can you do Cardio first thing in the morning?
*
Please Select
YES
NO
Motivation Level
*
5
6
7
8
9
10
How motivated are you reaching your goal?
Estimated Bodyfat %
Please Select
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
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28
29
30
31
32
33
34
35
Your best guess
Foods you like - Must Have's
*
Foods you Dis-like
What is your daily routine
*
Stress Level
*
Please Select
Little to no stress
slight to moderate stress
moderate stress
Above average stress
Heavy Stress
Meal Frequency - How many meals per day do you current have
*
Please Select
2 meals per day
3 meals per day
4 meals per day (1 snack)
5 meals per day (1-2 snacks)
6 meals per day (2-3 snacks)
Please select one
Is 3 meals per day with snacks in between an issue?
*
Please Select
YES
NO
Current Body Picture (before Pics)
Upload a File
pdf, doc, html, zip, mp3, avi, jpg, png etc.
Cancel
of
Do you have difficulty sleeping
Please Select
Yes
no
Do you feel sluggish/tired in the morning
Please Select
Yes
no
Have your tried Previous Diets?
Please Select
Yes
no
If so describe what happened good or bad
Any Medical Conditions
*
Please Select
Yes
no
Any Food Allergies
*
Please Select
Yes
no
If yes please explain
Phone Number
*
-
Area Code
Phone Number
E-mail
*
What is your time frame to reach your goal
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2017
2016
2015
Year
Notes
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