Online Enquiry Form

Full Name

First NameLast Name

Phone number

Would you like to schedule a phone consultation?

Email

example@example.com

Date of Birth

MonthDayYear

Age

years

Height

cm

What do you do for a living?

Whats the activity level at your job?

Would you prefer gym or home workouts or a mixture of both

Do you follow a regular working schedule, do you work days, afternoons or nights?

If you have any diagnosed health problems please list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given injury?

If you have any injuries, please list them.

Do any diseases run in your family?

Biggest strengths?

Biggest weaknesses? Things you want to work on

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

if yes please list:

Are you a current cigarette smoker?

Your current diet could be best characterized as:

Please rate your readiness for change.

Which of the following best describes your goals?

What is your goal with your training?

Why?

Timeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?

Are you currently excersising regulary (at least 3x per week)?

Have you ever had an online coach before?

If yes what kind of training did you do:

What are your expectations on me as your coach?

Are you ready to make the changes you have always wanted today!

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!