Pre Coaching Questionnaire
Name
First Name Last Name
Date of Birth
Month Day Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Timezone
Height
Weight
Body Fat % (if known)
Gender
Service you are applying for:
Do you have/ have you ever had
A doctor tell you that you have a heart, kidney, or liver condition, or have ever suffered a stroke? ?Anyone in your family under 60 suffering heart disease, stroke, raised cholesterol, or sudden death? Have you been hospitalized recently? Do you have any other medical condition that may make it dangerous to alter your nutrition, lifestyle, or exercise? Are you pregnant or have you given birth in the last 12 months? Do you ever feel faint, dizzy, or experience unexplained chest pains when exercising? Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
I believe all information stated above is true and accurate. I recognize that Jake Doleschal Nutrition and Fitness Coach is not able to provide me with medical advice regarding my medical condition(s), and that this information is used as a guide to the limitations of my ability to exercise.
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What are your 3 highest priority goals you want to achieve in regards to your fitness, body composition, or health goals?
What has kept you from starting sooner?
What are you realistically prepared to do in order to achieve these goals?
On a scale of 1-10, how would you rate your energy levels throughout the course of a day? Explain
On a scale of 1-10, how would you rate your overall stress levels throughout the course of a day? Explain
Would you rate your libido as high or low?
Do you smoke or have you smoked in the past? If so, for how long and how many cigarettes per day?
Do you drink alcohol or have you consumed alcohol in the past? If so, for how long and how much alcohol per day/week would you consume?
How many litres of water do you consume in an average day?

Do you currently take any supplements? If so, what type, why, are you taking it, what dose, and how long have you taken it for?
Do you currently take any prescription medication? If so, what type, why, what dosages, and how long have you taken it for? (This includes any contraceptive medication).
*Please list all foods and liquids you consume on a ‘normal’ day: (Please list calories and macronutrient breakdown if known – I suggest logging on MyFitnessPal and attaching image below of total daily calories and macros if able)
Attach MyFitnessPal Screenshots (optional)
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What is your current exercise program? How long have you been following it? Include approx. duration of sessions in a typical week
How many steps do you average per day? (According to your phone health app, or an activity tracker)
Do you NOT HAVE access to any of the following equipment?
Lying Leg Curl Squat Rack Various weighted DB's and BB's Back Extension Adjustable benches (incline and decline) Cables Resistance Bands Hack Squat or Pendulum Squat Trap Bar Deadlift
Please attach a starting photo from front on (in relaxed position with hands by side, taken in work out attire, swim suit or underwear)
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Please attach a starting photo from side on
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Please attach a starting photo from back
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I acknowledge that any dietary or supplemental suggestions made by Jake Doleschal Nutrition and Fitness Coach are guidelines only and not intended as the diagnosis, cure, or treatment for any disease. I acknowledge that I am legally responsible for all food and supplements that I consume, and that my medical physician is my primary health care provider responsible for supervising changes in diet and nutrient intake.
I understand that progress photos are required to be taken at the beginning of the program and at regular intervals, and understand that these photos may be published on social media without receiving any compensation from the use of these images
I hereby relinquish and waive all responsibility of any health complications that may arise by following the nutritional guidelines given to me by Jake Doleschal Nutrition and Fitness Coach. I have read, understood, and agree to the above conditions.
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Pre Coaching Questionnaire