Victoria Dales Coaching -
New Client Coaching Form
Please Complete this form to provide me with the necessary information to design your personalised nutrition and training program
Name
First Name
Last Name
Age
Weight (KG or Lb-please state)
Height (KG or Lb-please state)
Waist Measurement (cm or inch- please state)
Main Goal:
Fat Loss
Muscle Gain
Healthier Lifestyle
Contest Prep
Photoshoot/ wedding/ holiday/ occasion
Specific Goal- (eg, occasion date/ show date)
Work/ Daytime Activity Level:
Sedentary/ Desk Job
Moderately Active/ on feet
Highly Active/ Manual Job
Leisure Activity Level:
Inactive- very little exercise, occasional walking
Moderately Active- light to moderate exercise 3-4 times per week, gym sessions, brisk walks, swimming, dance/ aerobic classes etc
Very Active- exercise almost every day, eg, running, spinning, HIIT, Intense weight sessions
Average Daily Step Count If known)
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How many meals would you prefer to eat per day?
Please Select
3 main meals 2 snacks
4 main meals 2 snack
5-6 balanced meals throughout the day
Please select any food sources you DISLIKE:
Chicken
Turkey
Steak
Lean beef mince 5%
White Fish
Tuna
Prawns
Salmon
Bacon
Heck Sausages
Whey Protein
Potato
Rice
Pasta
Bread
Bagels
Oats
Cereal
Eggs
Avocado
Cheese
Nuts
Dark Chocolate
Peanut Butter
Almond Milk
Greek Yoghurt
Current diet/ calories/ macro split (if known)
Please state any food allergies/ intolerances
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Do you have a gym membership?
Yes
No
How may times are you able to workout per week?
3
4
5
Any Medical Conditions/ Injuries?
Do you take any regular medication?
Do you use any supplements? (vitamins/ whey/ pre workout/ intra workout etc)- please state brands
Do you currently or have you previously used and PED's (Preforming enhancing drugs)?
Yes
No
If yes, please state what, when and duration of use
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Females Only
Which best describes you?
Regular Menstrual Cycle
Irregular Menstrual Cycle
Hypothalamic Amenorrhoea (No Periods)
Postmenopause
Do you use any birth control? If so please state
Submit
Should be Empty: