Application

Coaching Application
Full Name *

First Name Last Name
Gender

Male Female Non-binary
Date of Birth *

Month Day Year
Age
years
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?
How often do you travel?

Rarely A few times a year A few times a month Weekly
Please list the physical activities that you participate in outside of the gym and outside of work.:
Are you experiencing any stresses or motivational problems?

Yes No
Has anyone of your immediate family developed heart disease before the age of 60?

Yes No
Do any diseases run in your family?

Yes No
Do you suffer from diabetes, asthma, high or low blood pressure?

Yes No
if yes please list:
Are you a current cigarette smoker?

Yes No
Your current diet could be best characterized as:

low-fat low-carb high-protein Vegetarian/Vegan No special diet
Please rate your readiness for change.

1 2 3 4 5 6 7 8 9 10
What do you want from coaching?
What following goals does best fit in with your goals?

Improved health Improved endurance Increased strength Increased muscle mass Fat loss Add muscle Look better Feel better Get control of eating habits Healthy aging More energy and vitality Reduce or eliminate medications Other
What is your goal with exercise & nutrition?
Why?
How specifically would you like your habits, your health, your eating, and or your body to be different?
Are you currently excersising regulary (at least 3x per week)?

Yes No
Please rate your motivational level to do what it takes for reach your goal.

1 2 3 4 5 6 7 8 9 10
Have you trained with a personal trainer before?

Yes No
If yes what kind of training did you do:
Have you worked with a nutrition coach before?

Yes No
What are your expectations on me as your coach?
Out of all the changes you'd like to make, what feels most important/urgent?
Until now, what has blocked you from making changes?
What have you tried?
How much time would you estimate you spend thinking about food each day?

0-20% 20-40% 40-60% 60-80% 100%
List any diets you've tried in the last 10 years.

Right now, how would you rate your overall eating habits?

	1	2	3	4	5

1 is Worst, 5 is Best

How much time in the last 10 years have you spent dieting?

0-2 2-4 4-6 More than 6

Given the demands of your life, what is your typical stress level on an average day?

	1	2	3	4	5

1 is Worst, 5 is Best

How much sleep do you get on average?

8+ hours 7-8 5-6 4 or fewer
How do you normally cope with your stress?
Spend a few words giving me some fun facts about yourself :-)
Anything I haven't asked that you'd like to share?
Email
example@example.com
Phone Number

Area Code Phone Number
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Coaching Application

What do you want from coaching?

What have you tried?