Client Consultation Form
The Wellness Affair
Personal Profile
Tell us about you
Name
*
Prefix
First Name
Last Name
DOB
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (00) 00000000.
Occupation
*
Working Arrangements
*
38+ hours per week
15-35 hours per week
15 hours or less per week
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Health & Fitness Goals
What do you hope to achieve from this program?
What attracted you to want to do this program?
*
What is your number one goal right now?
Please select the number which best represents your needs by importance; 1 being extremely important, 3 being somewhat important & 5 being not important.
*
1
2
3
4
5
I want to be fitter
1
1 is I want to be fitter, 5 is
*
1
2
3
4
5
I want to get stronger
2
1 is I want to get stronger, 5 is
*
1
2
3
4
5
I need more energy
3
1 is I need more energy , 5 is
*
1
2
3
4
5
I Want more muscle
4
1 is I Want more muscle , 5 is
*
1
2
3
4
5
I Want more muscle definition (toning)
5
1 is I Want more muscle definition (toning), 5 is
*
1
2
3
4
5
I Need to get more flexible
6
1 is I Need to get more flexible, 5 is
When would you like to achieve your goal by?
3 months
6 months
12 months
24 months
Why is this goal so important to you?
Are there any reasons you haven’t been able to achieve this goal on your own?
Are you currently playing sport or following an exercise plan?
*
Yes
No
If yes, how often & how hard is this activity?
Have you followed any specific training plans before?
*
Yes
No
If yes, did you successfully achieve your goal when you were following the plan? Why? If not, why not?
Which best describes you?
Self motivated
Prefer a training partner
Need regular help
Tend to lose motivation
On a scale of 1-5, describe how you are feeling at the moment: How energetic are you?
*
1
2
3
4
5
I just want to sleep
I am the energiser bunny
1 is I just want to sleep, 5 is I am the energiser bunny
How healthy do you feel?
*
1
2
3
4
5
I am always sick
I rarely need to see a Dr.
1 is I am always sick, 5 is I rarely need to see a Dr.
How fit do you feel?
*
1
2
3
4
5
I get puffed looking at stairs
I could run the stairs while chatting
1 is I get puffed looking at stairs, 5 is I could run the stairs while chatting
How strong do you feel?
*
1
2
3
4
5
I need help carrying my groceries
I can bench my own body weight
1 is I need help carrying my groceries, 5 is I can bench my own body weight
When I look in the mirror;
*
1
2
3
4
5
I hate what I see and think about things I’d like to change
I feel confident in my skin and feel good about myself
1 is I hate what I see and think about things I’d like to change, 5 is I feel confident in my skin and feel good about myself
If I see people whispering nearby;
*
1
2
3
4
5
I automatically think they are talking about me
I don’t pay any attention, I am unshakable
1 is I automatically think they are talking about me, 5 is I don’t pay any attention, I am unshakable
How would you describe your mindset?
*
1
2
3
4
5
What is mindfulness?
I am a spiritual gangster
1 is What is mindfulness? , 5 is I am a spiritual gangster
How much time are you willing to dedicate to training?
Are you currently following any particular diet or eating plan? If yes which one?
*
What do you find is your biggest challenge when it comes to being healthy and well?
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Adult Pre-Exercise Screening tool
This screening tool doesn’t not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by exercise and sports science Australia, fitness Australia or sports medicine Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.
Has your Dr ever told you that you have a heart condition or have you ever suffered a stroke?
*
Yes
No
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
*
Yes
No
Do you ever feel faint or have spells of dizziness during physical activity/exercise that cause you to lose balance?
*
Yes
No
Have you ever had an asthma attack requiring immediate medical attention at any time during the last 12 months?
*
Yes
No
If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?
*
Yes
No
Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
*
Yes
No
Do you have any other medical condition that make it dangerous for you to engage in physical activity/exercise?
*
Yes
No
Signature
*
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