BODYTEMPLE
BOOT CAMP
by Kieba
BOOT CAMP
by Kieba
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BODYTEMPLE BOOT CAMP by Kieba |
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Kieba's Camper Questionnaire |
You may print this Questionnaire, fill it out and mail the completed form to: Dawn Blacklidge - Kieba, 13-510 Hinalo St., Pahoa, HI 9778 |
| Current Specifics: |
| Age: |
| Height: |
| Weight: |
| BMI or Body Fat % if known: |
| Body type: (slender, athletic, a few extra pounds, etc.): |
| Past Exercise Activities: | Frequency and duration: |
| Running: | |
| Biking: | |
| Walking: | |
| Swimming: | |
| Aerobics: | |
| Weight training: | |
| Other: |
| Current Exercise activities: | Frequency and duration |
| Running: | |
| Biking: | |
| Walking: | |
| Swimming: | |
| Aerobics: | |
| Weight training: | |
| Other: |
| Overall Physical Health: |
| Current medications | |
| Recent or past surgeries | |
| Recent or past injuries | |
| Strengths: | |
| Weaknesses: | |
| Current aches and pains: | |
| Any family history of health issues? | |
| Anything else we should be aware of? |
| Overall Emothional Health: |
| Depression or mood swings? | |
| Past or current addictions? | |
| High or low stress level? | |
| Other: | |
| Anything else we should be aware of? |
| Goals for physical body weight: |
| 3 months: | |
| 6 months: | |
| 12 months: |
| Current dietary practices: |
| Currently following a diet plan? | |
| Junk food junkie? | |
| Food cravings? | |
| Favorite food? | |
| Least favorite food? | |
| Comfort food/snack? | |
| Food allergies? | |
| Anything else we should be a aware of? | |
| Eating disorders? | |
| Typical Breakfast: | |
| Typical Lunch: | |
| Typical Dinner: | |
| Typical snacks: | |
| Weekly alcohol consumption: |
| Mental / Spiritual / Philosophical questions: |
| What are your biggest 'life' concerns or stressors: |
| How do you deal with stress? |
| Do you enjoy your alone time? |
| Ar you comfortable with your SELF? |
| What types of books do you enjoy reading |
| Who are the people you admire most? Why? |
| Why did you choose this boot camp? (were you referred?) |
| What are your "expectations" of the boot camp? |
| What do you want to take home after your experience here? |
| If you could change one thing about your life, what would it be? |
| Ar you willing to be open minded and put aside your current 'programmed' beliefs to learn and experience new things that could improve your well being? |
| Other Questions: |
| Please list an emergency contact: Name, Phone Number, Relationship. |
| Are you willing to sign a waver or release in case of injury while here? |
| Would you be interested in a follow up program after the camp to continue reinforcing new behaviors and habits? |
| Do you have any thoughts or concerns about the camp that you would like to discuss |
| Please mail the completed form to: Dawn Blacklidge - Kieba 13-510 Hinalo st Pahoa, HI 9778 |
In case of questions, feel free to email or call me at: Namaste, Kieba |