Gainz Coach Consultation Form

Full Name*

First NameLast Name
Email*
example@example.com
Mobile Phone Number*

Country Code Mobile Phone Number
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
cm
Weight*
KG
What do you do for a living?*
Whats the activity level at your job?*

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?*
Please list the physical activities that you participate in outside of the gym and outside of work.:*
If you have any diagnosed health problems list the condition(s).*
If you are on any medications, please list them.*
What additional therapies are being undertaken for the given health problem(s)?*
If you have any injuries, please list them.*
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?*

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?*

YesNo
Do any diseases run in your family?*

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
if yes please list:
Are you a current cigarette smoker?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Any Nutrition Restrictions?*
What following goals does best fit in with your goals?*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?*
Why?
Are you currently excersising regulary (at least 3x per week)?*

YesNo
Have you trained with a personal trainer before?*

YesNo
If yes what kind of training did you do:
At what times during the day would you prefer to train?*

MorningMid-DayAfternoonEvening
Are you willing to train 4-6 days a week to reach your goal?*
Please Choose
What are your expectations on me as your Personal Trainer?*
Are you willing to invest just $300 per month into finally achieving the body of your dreams?*

YesNo
1.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo

My Products*

1 on 1 coaching 1 on 1 coaching $300/month

$300.00

Total

$0.00

Payment Details
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