K.N.E.E. Coaching Program Survey GENERAL INFORMATION What's your email? GENERAL INFORMATION What's your age? Select your age Under 35 35-44 45-54 55-64 65-74 75 or older GENERAL INFORMATION How did you find us? Email Socials Other GENERAL INFORMATION What is your Body Type Classification? Description: Ectomorphs are typically slim and have a hard time gaining weight or muscle. They usually have a fast metabolism, long limbs, and narrow shoulders. Common Traits: Thin build, low body fat, small joints, and a delicate frame. Description: Mesomorphs have a naturally athletic build. They tend to gain muscle easily and have a well-defined, muscular physique. Their bodies are usually well-proportioned.Common Traits: Medium build, strong, and muscular, with broad shoulders and a narrow waist. Description: Endomorphs often have a rounder, softer body and may find it easier to gain weight, particularly fat. They might struggle to lose weight but can build muscle with effort.Common Traits: Higher body fat, thicker joints, and a wider frame, with a tendency to store fat in the lower body. PHYSICAL FITNESS LEVEL INFORMATION What is your current physical activity level? Light: desk work, standing for long hours, clerical work, administrative and managerial staff, driving light vehicles, housewives with light housework. Moderate: cleaning/domestic services/work, home building tasks, farming, patient care Very active or vigorous:tasks requiring strenuous effort and extensive total body movement like physical education instructor, firefighting, construction work, coal mining, manually shoveling. PHYSICAL FITNESS LEVEL INFORMATION How often do you engage in physical exercise or activity? Daily Once a week Two times a week Three times a week Never PHYSICAL FITNESS LEVEL INFORMATION What types of exercise do you prefer? (Check all that apply) Walking Running Swimming Yoga Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Musculoskeletal Issues: (Check all that apply) Arthritis: Pain and stiffness in the joints can limit movement. Osteoporosis: Increased risk of fractures can make certain activities unsafe. Chronic Back Pain: Limits ability to perform many types of exercises. Joint Injuries: Sprains, strains, and other injuries can restrict movement. PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Cardiovascular Conditions: (Check all that apply) Heart Disease: Conditions like coronary artery disease can limit physical exertion. Hypertension/Hypotension Peripheral Artery Disease: Reduced blood flow to limbs can cause pain and limit activity. Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Respiratory Issues: (Check all that apply) Asthma: Can cause difficulty breathing during exercise. Chronic Obstructive Pulmonary Disease (COPD): Limits breathing capacity, making exercise challenging. Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Neurological Disorders: (Check all that apply) Multiple Sclerosis (MS): Can cause muscle weakness and coordination problems. Parkinson's Disease: Tremors and rigidity can limit mobility. Stroke: Can result in partial paralysis or weakness on one side of the body. Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Metabolic Conditions: (Check all that apply) Diabetes: Risk of hypoglycemia during exercise. Obesity: Excess weight can strain joints and limit movement. Hyperthyroidism Hypothyroidism Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Balance and Coordination Problems: (Check all that apply) Vertigo: Affect balance and spatial orientation. Muscle Weakness: Can lead to instability and falls. Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Chronic Pain Conditions: (Check all that apply) Fibromyalgia: Widespread pain and fatigue can limit exercise tolerance. Chronic Fatigue Syndrome: Severe fatigue that worsens with physical activity. Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Post-Surgical Recovery: (Check all that apply) Hip replacement Knee replacement Shoulder replacement Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Autoimmune Diseases: (Check all that apply) Lupus: Can cause joint pain and fatigue. Rheumatoid Arthritis: Can cause joint damage and pain. Chronic Urticaria Other PHYSICAL FITNESS LEVEL INFORMATION Do you have any physical limitations that affect your ability to exercise? Injuries: (Check all that apply) Fractures: Healing bones need to be protected from strain. Torn Ligaments/Tendons: Limit the ability to move certain body parts. Other LIFESTYLE INFORMATION How many hours do you spend sitting or being inactive each day? 0-6 hours 7-12 hours 13-18 hours LIFESTYLE INFORMATION How many hours of sleep do you typically get each night? 4 hours 6 hours 10 hours or more Other LIFESTYLE INFORMATION Do you smoke or use tobacco products? If so, how much and how often? No Occasionally Yes. Once a week. 0-5 sticks per day Yes. Once a week 6-10 sticks per day Yes. Twice a week. 0-5 sticks per day Yes. Twice a week. 6-10 sticks per day Yes. Three times a week. 0-5 sticks per day Yes. Three times a week. 6-10 sticks per day Other LIFESTYLE INFORMATION Do you consume alcohol? If so, how much and how often? No Occasionally Yes. Once a week. 0-5 bottles/glasses per day Yes. Once a week 6-10 bottles/glasses per day Yes. Twice a week. 0-5 bottles/glasses per day Yes. Twice a week. 6-10 bottles/glasses per day Yes. Three times a week. 0-5 bottles/glasses per day Yes. Three times a week. 0-5 bottles/glasses per day Yes. Three times a week. bottles/glasses per day Other LIFESTYLE INFORMATION Are you currently taking any prescription or over-the-counter medications? Yes. Please specify medications below (other) No. Yes. Once a week. 0-5 bottles/glasses per day Other LIFESTYLE INFORMATION How would you describe your stress levels on a typical day? Mild- Occasional tension, worry, or nervousness with minor physical symptoms like slight headaches or mild sleep disturbances. Minimal interference with daily activities, easily managed with simple coping strategies like exercise or hobbies. Moderate- Frequent anxiety, irritability, or frustration with physical symptoms such as frequent headaches or notable sleep problems. Noticeable effect on daily life, reducing productivity and enjoyment. Requires structured coping strategies like mindfulness or counseling. Severe- Persistent and overwhelming anxiety, panic, or hopelessness with severe physical symptoms such as chronic headaches or significant sleep disturbances. Major impairment in daily functioning, often needing professional intervention like therapy or medication. LIFESTYLE INFORMATION What are your main sources of stress? (Check all that apply) Work Family Financial Other LIFESTYLE INFORMATION How often do you participate in social activities or hobbies? Daily Weekly Monthly Other LIFESTYLE INFORMATION How often do you spend time with friends or family? Regularly (2 to 3 times per week) Seldom (Once a month) Never Other LIFESTYLE INFORMATION How is your housing situation? (Check all that apply) Single- Story Multiple- Story Permanent Live with family/relatives Senior/retirement community with accessibility features Assisted living facility Temporary housing (e.g., rehabilitation center, hotel) Other LIFESTYLE INFORMATION Are you currently participating in an exercise program or undergoing rehabilitation with a physical therapist? Yes, I am enrolled in an exercise program. Yes, I am undergoing rehabilitation with a physical therapist. Yes, I am doing both. No, I am not currently enrolled in any exercise program or rehabilitation. Other NUTRITION INFORMATION Do you have any diagnosed food-related diseases? (Check all that apply): Diabetes Celiac Disease Food Allergies Other NUTRITION INFORMATION How long have you been living with this condition? Less than 1 year 1-2 years 3-5 years More than 5 years Other NUTRITION INFORMATION Do you follow any specific dietary restrictions due to your condition? Yes No NUTRITION INFORMATION If yes, please specify the dietary restrictions: Gluten-free Dairy-free Low sugar Other NUTRITION INFORMATION How often do you read food labels to check for ingredients related to your condition? Never Rarely Sometimes Often Always COMMITMENT LEVEL How much are you willing to commit yourself to this coaching program? Fully Committed: "I am fully committed and ready to give my best effort to follow all the guidance and recommendations provided." Very Committed: "I am very committed and will make this program a top priority in my daily schedule." Moderately Committed: "I am moderately committed and will do my best to follow the program, but I might have some limitations due to other responsibilities." Somewhat Committed: "I am somewhat committed and will try to participate as much as I can, but I may not be able to follow everything consistently." Not Sure Yet: "I am not sure yet. I need more information about the program before I can determine my level of commitment." Not Very Committed: "I am not very committed at this time and may find it challenging to follow the program regularly." Not Committed: "I am not committed to this program and don't think I can follow it at this time." COMMITMENT LEVEL How much are you willing to invest in a coaching program? Below 50 USD 51-100 USD 101-500 USD Above 500 USD COMMITMENT LEVEL How soon can you start? Immediately: "I can start right away" Within A Few Days: "I can start within the next few days." Next Week: "I am ready to start next week." In Two Weeks: "I need about two weeks before I can start." Next Month: "I can start next month." Need More Time: "I need more time to prepare, but I can provide a specific date soon." ❮ Previous Next ❯ Submit
