CC Coaching Health screening form

Date

D.O.B

Name

Email

example@example.com

Mobile

Height

Weight

Emergency contact name

Mobile

Occupation

Describe your activity levels on average (eg. steps, sports, work)

How many hours sleep do you get on an average night?

What are your top 3 barriers to getting a good nights sleep?

How stressed are you currently out of /10?

What causes you the most stress?

What is the main reason for starting with myself ?

What are your health and fitness goals?

Is there a time frame for this goal?

How dedicated are you to achieving this goal?

What are the top 3 barriers to you reaching this goal?

Rate your confidence in the gym /10

What is your training experience?

Do you suffer from any of the following?

Chest pains

YesNo

Heart problems

YesNo

High blood pressure

YesNo

Asthma

YesNo

Dislocations

YesNo

Diabetes

YesNo

Epilepsy

YesNo

Feeling faint/dizzy spells

YesNo

Injuries

YesNo

If you have answered yes to any of the following questions then please provide information below and make sure your GP has give you the all clear to exercise.

Sign below to say you are happy with the information you have provided me as well as agreeing with the policy stated above.

Client Name

Client signature

Instructor Name

Instructor signature