Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Please list your height (in cm's), weight (kg's) and body fat percentage (if known)
Has a doctor stated you have high blood pressure?
*
Have you suffered from either heart disease, stroke, sudden death, elevated cholesterol?
*
Are you currently on prescribed medication? Does it effect your training?
*
Do you have or have you suffered from diabetes?
*
Have you had any blood tests conducted in the past 6 months?Was there anything to be concerned about?
Are you currently seeing any medical specialists atm? Please elaborate.
Are you pregnant or have given birth in the past 6 months?
*
Is there anything that hasn’t been mentioned that could potential affect your health and well being in relation to your training program?
*
Please list any muscular or joint injuries, aches, limitations or pains.
*
How long have you been training for?
Have you followed an exercise program before?
What are your strongest lifts in those movements?
How many times per week will you commit to your training program?
How many hours of sleep on average do you get per night
What are the main contributors to your overall stress?
What is your occupation? What are the demands of your role physically and mentally?
How much time and what activities do you do to relax?
Please rate on the scale truthfully (1=Poor to 10=Excellent)
1
2
3
4
5
6
7
8
9
10
Overall energy levels
1
2
3
4
5
6
7
8
9
10
Overall stress
11
12
13
14
15
16
17
18
19
20
Mood
21
22
23
24
25
26
27
28
29
30
Anxiety
31
32
33
34
35
36
37
38
39
40
Strength/fitness
41
42
43
44
45
46
47
48
49
50
Select the preferences that apply
Tried it
Currently doing
No, open to trying
No interest in trying
Dont know
Meat 3 veg
51
52
53
54
55
Paleo
56
57
58
59
60
Vegetarian
61
62
63
64
65
Vegan
66
67
68
69
70
High Protein
71
72
73
74
75
Macros
76
77
78
79
80
Clean Eating
81
82
83
84
85
Fasting
86
87
88
89
90
Portion Control
91
92
93
94
95
Diet Snapshot
Do you:
Yes
No
Drink Coffee Daily
96
97
Use Pre-workout more than 1 x per week
98
99
Drink alcohol more than once a week
100
101
Smoke ciggarettes
102
103
Drink 3L water per day
104
105
Drink soft drink regularly
106
107
Do you suffer from:
Yes
No
Joint Pain
108
109
Digestive Issues
110
111
Lethargy
112
113
Bloating
114
115
Bad Menstrual Periods
116
117
List your goals and give a brief description of what they mean to you
When would you like to achieve your results by?
Please answer the following truthfully
Confident
Somewhat Confident
Not Confident
Im prepared to track my food intake
118
119
120
Im prepared to fill in my training plan
121
122
123
Im prepared to send progress pictures as specified
124
125
126
Im prepared to fill in my tracking sheet
127
128
129
Im prepared to modify my diet
130
131
132
Im prepared to take supplements as necessary
133
134
135
Im prepared to modify my lifestyle habits
136
137
138
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