Welcome

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
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Birthday* This field is required.
Date
Month
Day
Year
4
Phone Number* This field is required.
Area Code
Phone Number
5
Age / Height (in cm's) / Weight (in Kg's) & BF (if known)* This field is required.e.g 27/182cm/75kg/15%
6
Average step count* This field is required.
7
WAIST MEASURMENT
8
Has a doctor stated you have high blood pressure?* This field is required.
YESNO
9
Have you suffered from either heart disease, stroke, sudden death, elevated cholesterol? * This field is required.
YESNO
10
Are you currently on prescribed medication? Does it effect your training?* This field is required.If yes please elaborate
11
Do you have or have you suffered from diabetes?* This field is required.
YESNO
12
Have you had any blood tests conducted in the past 6 months?Was there anything to be concerned about?* This field is required.If yes, please elaborate?
13
Are you currently seeing any medical specialists at the moment? * This field is required.If yes, please elaborate?
14
Is there anything that hasn’t been mentioned that could potential affect your health and well being in relation to your training program?* This field is required.
15
Please list any muscular or joint injuries, aches, limitations or pains.* This field is required.Please list date of the incident, any treatment/rehabilitation and if the condition still persists.
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Ok
16
How long have you been training for?* This field is required.
17
Can you Barbell Squat to parallel* This field is required.
YESNO
18
Can you Deadlift?* This field is required.
YESNO
19
Can you Bench?* This field is required.
YESNO
20
What are your best lifts? (PLEASE ADVISE HEAVIEST KG LIFTED FOR EACH) Squat, Dead, Bench?* This field is required.
21
How many times per week will you commit to your training program? * This field is required.
22
List your SPECIFIC goals and give a brief description of what they mean to you* This field is required.e.g PB numbers, Specific Skills, % of BF or CM goal etc - you don't need to know how but think, what is it is I'd love to do/achieve we will get more specific on this
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When would you like to achieve your results by? * This field is required.lets set some deadlines!
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Have you achieved results in the past? What were you doing and how long ago?* This field is required.Have you been where you want to be before?
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25
Please rate:* This field is required.
Energy Levels
Strength
Fitness
Sleep
Stress
Anxiety
Mood
Energy Levels
Strength
Fitness
Sleep
Stress
Anxiety
Mood
26
How many hours of sleep on average do you get per night?* This field is required.
27
I wake up tired most mornings* This field is required.
YESNO
28
I wake up and go to sleep at the same time every night* This field is required.
YESNO
29
Do you get 10-30 mins of exposure to natural light between waking up and 1pm?* This field is required.
YESNO
30
What is your occupation? What are the demands of your role physically and mentally?* This field is required.
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What are the main contributors to your overall stress?* This field is required.Examples. job commitments, sleep quality, diet, family commitments etc.
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32
How much time and what activities do you do to relax?* This field is required.
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33
What is the time frame between your last meal and your bed time?* This field is required.
34
Do you eat breakfast within 30-60 mins upon waking?* This field is required.
35
Do you have any food allergies or intolerance's?* This field is required.
36
Diet Snapshot* This field is required.
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37
What foods do you love & what foods do you dislike?* This field is required.PLEASE ALSO INCLUDE HOW MANY MEALS YOU ARE CURRENTLY EATING IN A TYPICAL DAY E.G 3 MEALS AN 2 SNACKS, 4 MEALS AND 2 SNACK, 2 MEALS, ETC
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38
Are you training at home or a gym - please provide information on what equipment you have access too: cables, leg press, squat racks, benches, free weights etc* This field is required.
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39
Do you
Yes
No
Drink coffee daily
Use pre workout more than once a week
Drink 3L+ of water per day
Smoke cigarettes
Drink soft drink regularly
Drink coffee daily
Use pre workout more than once a week
Drink 3L+ of water per day
Smoke cigarettes
Drink soft drink regularly
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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40
Please answer truthfully
Not Confident
Indifferent
Confident
Im prepared to track my food intake
I'm prepared to fill in my training plan
I'm prepared to send progress pictures as required
I'm prepared to modify my diet
I'm prepared to fill in my data tracker
Im prepared to track my food intake
I'm prepared to fill in my training plan
I'm prepared to send progress pictures as required
I'm prepared to modify my diet
I'm prepared to fill in my data tracker
Not Confident
Indifferent
Confident
Not Confident
Indifferent
Confident
Not Confident
Indifferent
Confident
Not Confident
Indifferent
Confident
Not Confident
Indifferent
Confident
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41
I confirm I will approach the goal setting model with my growth mindset and intention that I CAN do it, I will work through step by step in the video and written data to have a clear framework in which my coach (Rhi) can map out the path moving forward.
YESNO
42
Rhiannan Willis will make various efforts to minimise any potential risks. However, you must be aware that exercise has some potential side effects and risks. It is possible throughout the exercise assessment, training sessions or your program that you may experience abnormal blood pressure, irregular heart rhythm, dehydration, fainting and/or dizziness. It is also possible that you might seriously injure yourself from the use of exercise equipment, failure of exercise equipment, tripping or falling, or other hazards associated with equipment, moving around while exercising, and your surroundings. In very rare circumstances, it is possible that exercise can cause heart attack, stroke or death. It is extremely important that any physical or other symptoms that you experience whilst participating in the program are explained to staff, even if you feel that they might not be important. It is also important that you tell your trainer any information you possess about your health status, or changes to your health during the course of your program, especially those that relate to heart problems including shortness of breath, Informed Consent and Release of Information for Participation in Exercise pain, pressure, tightness or heaviness in the chest, neck, back, jaw, calf area and/or arms. By telling your trainer this information you are minimising your risk or injury, complications and death. It is expected that you will tell your trainer all medications you use, begin to use or cease using (including non-prescription) prior to participation in your initial or regular training sessions. It is also expected that any short term changes to your usual medication regime are reported to your trainer (e.g. forgetting to take your medication one morning). I understand all of the information and instructions outlined in this informed consent, have had time to discuss any concerns with a health professional, and considering this, agree to participate in a program at my own risk. I also agree to release and indemnify from or against any actions or claims arising from any injury, loss, damage or death caused to me. I also give permission for Rhiannan Willis to use my image / name in the of the above promotional outlets listed. I hereby consent to voluntarily engage in the exercise program considering the above information. I understand what is expected of me and the risks and procedures associated with this program. After fully reading this document I voluntarily consent to participate in the exercise program.
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