Initial Consultation Form

Initial Consultation Form

For correct, effective, and relevant programs and plans is to be given to you as a client, relevant information must be obtained prior writing your plans. Below is a detailed list of questions and information that we need to collect regardless of your goals.
BASIC INFORMATION
Name

First Name Last Name
Email
example@example.com
Age / Date Of Birth
Gender
Height in CM
Current Weight in KG (if known)
Body Fat Percentage (if known)
Ethnicity
Profession / Occupation
Hours spend working per week?
Home life (marital status, kids etc)
GOAL SETTING
It is important that you know what you want to achieve and WHY. So take a moment and get clear about what it is that you DO want.
How will you feel if you reach your goal?
How will you feel if you don't reach your goal?
What are you willing to do to reach your goal? Add as many options you can think of.

Commit to 3-5 training sessions per week Cut out alcohol from your diet Reduce eating out Cut out processed foods Take supplements Learn how to cook
How do you think reaching your goal will impact you life?
EXERCISE & NUTRITION HISTORY
If you've lost a large amount of weight before, please provide as many details as possible (when, how much, what timeframe, what method, how long before putting it back on, how did you feel after losing it)
If you've ever been on a nutrition plan, please provide as many details as possible (when, for how long, what for, how many diets have you tried, was any of them successful?)
What form of exercise have you completed in the past and what was your enjoyment level for this type of exercises?
Throughout your life, when did you feel at your best emotionally / mentally / physically?
What were you doing that contributed to that?
What were you NOT doing that contributing to that?
What injuries have you had in the past (if any)?
Have you had or do you have any known addictions?
Do you have a family history of any below:

Cancer Diabetes Heart Disease High Blood Pressure High Cholesterol Hyperglycaemia Obesity Osteoporosis
CURRENT EXERCISE, NUTRITION & LIFESTYLE
What are you currently doing for exercise? (what type, how often, at what effort)
Is there anything you don't eat due to ethical or cultural reasons?
How many meals per day do you eat (including snacks)?
List the most common 10-15 foods you eat in a week:
How often do you consume wheat products?
How often do you consume diary products?
How often do you consume fresh / frozen fruit?
How often do you consume fresh / frozen vegetables?
How many caffeinated drinks do you consume each day? (coffee / soft drinks / energy drinks / green tea / black tea)
How often do you consume sugary fruit juices or soft drinks?
How often do you consume alcohol?
How many liters of water do you consume each day?
Do you smoke cigarettes? (If yes: how may per day, If have been: how long did you smoke for and when did you quit)
Do you have any known allergies? (list all)
If you are currently taking any medication, please list below and include how long you've been taking them:
Are you taking any supplements? (If yes: list below and include brand, If no: do you have anything against them)
Are you open to take supplements should we recommend you any?
Do you have a max budget we would have to consider when it comes supplements?
What is your current activity levels?

Sedentary (desk job with little to no exercise) Little Activity (exercise moderately 1-3x per week OR no exercise but slightly active job) Moderate (exercise 2-3x per week with sedentary job OR slightly active job and exercise 1-3x per week Active (physical work, exercise hard 5+ days per week) Highly Active (physical work, exercise very hard 6+ days per week
Do you have any CURRENT injuries or restrictions?
SLEEP ASSESSMENT
What time do you wake up and go to bed?
How many hours do you sleep at night?
Do you wake up at night? How often and why?
Are you sleeps restless? (waking up tangled in sheets)
Do you wake up well rested or do you feel more tired than when you went to bed?
Do you snooze or get straight out of bed in the morning?
What time of the day are you the most energetic?
What is your morning routine like?
What is your evening routine like?
WELLBEING ASSESSMENT
Describe how you feel when you don't workout or miss a scheduled workout.
Describe how you feel when you eat something that is not listed on your nutrition plan, or something that you know is "bad" for you.
Describe how you feel then you resist temptation when going out for dinner.
Describe how you feel when someone comments on your weight in a positive way.
Describe how you feel when someone comments on your weight in a negative way.
Describe how you feel when you miss a meal.
Describe how you feel when you overeat.
DIGESTION ASSESSMENT
Do you... (tick as many as applies)

Go to the toilet every day? Often feel bloated? Often get gassy? Get any other gut distress after eating? Often get constipated? Often get diarrhea? Use laxatives or stool softeners?
Put down any more notes on the above if needing to clarify:
STRESS ASSESSMENT
Do you have dark circles under your eyes?
How is your short / long term memory?
Do you... (tick off as many as applies):

Feel or get easily overwhelmed? Have sugar cravings? Feel anxious? Feel easily aggitated? Have an impaired ability to handle stress? Feel despair? Get sick often / frequently? Have a low tolerance to pain? Have daily crashes in energy? Have noticeably more weight around your midsection? Perform any sort of meditation or relaxation? (incl. yoga)
Put down any more notes on the above if needing to clarify:
List your current top 3 biggest stresses in life:
FOR LADIES
Do you use any contraception? If yes, which one and how long?
Have you used contraception? If yes, which one, how long for and how long since you stopped?
If not using contraception, do you have regular cycle (24-35 days)?
If not regular cycle, do you know why you have an irregular or absent cycle? (example PCOS or menopause)
PLANNING & MAKING THE PLAN WORK
Where will you be training?

In fully equipped gym At gym, prefer classes At home, with no equipment At home, with some equipment
If training at home, what equipment do you have available to you?
How many times per day can you realistically commit to training over the next 12 weeks?
What are you IDEAL training days?
What time will you MOST LIKELY train on?
How long can a session MAXIMUM last for?
We've covered a lot of information to be able to create your tailored plan. Is there anything that haven't been covered that should be added to this?
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Initial Consultation Form

BASIC INFORMATION

GOAL SETTING

EXERCISE & NUTRITION HISTORY

CURRENT EXERCISE, NUTRITION & LIFESTYLE

SLEEP ASSESSMENT

WELLBEING ASSESSMENT

DIGESTION ASSESSMENT

STRESS ASSESSMENT

FOR LADIES

PLANNING & MAKING THE PLAN WORK