Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
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 did you hear about my self and coaching services
Instagram
Word of Mouth
A friend
Facebook
TikTok
Other
How long have you been training for?
Have you followed a structured exercise program before? If so how long ago and what where you doing?
How competent are you in the gym in relation to your exercises and training?
I know most movements and am very confident performing them
I know the basic movements and can perform them well
I don't know many movements in the gym and am unsure If I do them well
I am extremely competent and confident in the gym with all movements
How many times per week will you commit to your training program?
What time of the day is the best time to train for you?
List your goals and give a brief description of what they mean to you
When would you like to achieve your results by?
Have you achieved results in the past? What were you doing and how long ago?
Are there any movements or exercises that you enjoy in your training?
Are there any movements or exercises that we need to AVOID in training? If yes please explain why.
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
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?
Do you have any food allergies or intolerance's?
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
Please answer the following truthfully
Confident
Somewhat Confident
Not Confident
Im prepared to track my food intake
108
109
110
Im prepared to fill in my training plan
111
112
113
Im prepared to send progress pictures as specified
114
115
116
Im prepared to fill in my tracking sheet
117
118
119
Im prepared to modify my diet
120
121
122
Im prepared to take supplements as necessary
123
124
125
Im prepared to modify my lifestyle habits
126
127
128
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Signature provided by Client
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