Online Training enquiry + PAR-Q Form
1. Personal Information
Name
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Please Select
Female
Male
Prefer not to say
Height:
*
enter in cm
Weight:
*
enter in kg
Email
*
example@example.com
Contact number
*
-
Country Code
Phone Number
Emergency contact
*
-
Country Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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2. Lifestyle Information
Are you currently studying?
*
Give as much detail as possible about your studies
Are you currently employed?
*
Give details of your role and obligations
What are your weekly work/study hours like?
*
If yes, give as much detail as possible about the days/times you work/study
How active are you in your work/study time?
*
I'm sat down most of the day
I'm stood up most of the day
I'm very active for most of the day
I do a lot of heavy lifting
Other
How active are you in your free time?
*
I'm sat down most of the day
I'm stood up most of the day
I'm very active for most of the day
I do a lot of heavy lifting
Other
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3. Health/Medical Information
Do you have any diagnosed health/medical conditions that I should be made aware of?
*
Yes
No
If you do, please list them here. Be as detailed as you can about, what it is, how it affects you and how you are managing your symptoms
*
Type 'not applicable' if you answered 'No' to the previous question
Have you had any injuries recently or in the past that I should be made aware of?
*
Yes
No
If you do, please list them here. Be as detailed as you can about, what it is, how it affects you and how you are managing your symptoms
*
Type 'not applicable' if you answered 'No' to the previous question
Do you smoke?
*
Yes
No
Occasionally
Other
Do you drink alcohol?
*
Yes
No
Occasionally
Other
How many hours of sleep do you get on average per night?
*
4 hours or less
5-7 hours
8+ hours
I don't know
How many steps on average do you do per day ?
*
less than 3000
3000-5000
5001-8000
80001-9999
1000+
I don't know
How are you tracking your steps ?
*
Fitbit
Apple Watch
Galaxy Gear/Galaxy Active
Other smart watch
Mobile phone step tracker
Other device
Just a guess
I don't know
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4. Your Goals
What is your main reason for taking up this programme?
*
Give as much details as possible about any specific, measurable goals you have
What areas of your health and fitness do you want to focus on?
*
Weight loss
Gain muscle
Confidence
Lifestyle changes
Gain strength
Nutritional guidance
Help to be consistent
Accountability
Training knowledge
Other
If you achieve these goals, how will it affect your life?
*
Give as much details as possible
Realistically when do you want to achieve your goals?
*
8 WEEKS
12 WEEKS
16 WEEKS
24 WEEKS
32 WEEKS
40 WEEKS
1 YEAR
1+ YEARS
START
What has stopped you in the past from achieving these goals?
*
Give as much detail as possible
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5. Diet & Nutrition
How often do you eat fast food/takeaways? Be honest.
*
less than once a month
twice a month
once a week
more than once a week
every day
never
How often do you eat eat out at restaurants/cafes? Be honest.
*
less than once a month
twice a month
once a week
more than once a week
every day
never
Do you want any help from me with nutirtion?
*
Yes - weight management
Yes - Muscle growth
Yes - making better food choices
No thanks
What specifically would you like support with?
*
Give as much detail as possible. If you answered 'No' then type 'Not Applicable'
Do you have any dietary restrictions?
*
List any allergies, intolerances, medical conditions causing restrictions
Has anything been successful for you in the past diet and nutrition wise?
*
What have you struggled with in the past diet and nutrition wise?
*
Have you tracked calories before?
*
Yes - MyFitnessPal
Yes - another app
No
Is there anything else that could affect your aility to adhere to a diet that you need to consider?
*
i.e. social events, family events, holidays, religious obligations etc.
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6. Training Sessions
How many times a week do you train/workout?
*
Zero
1-3 days per week
3-5 days per week
6-7 days per week
How long have you been training?
*
less than 6 months
6 months - 1 year
1-2 years
2+ years
Other
What kind of training do you do?
*
Weight training in the gym
Gym classes
Home/Outdoor workouts
Personal Training sessions
Other
Why do you do this kind of training?
*
What kind equipment do you have access to use in your in your programme?
*
Fixed resistance machines
Cable machines
Functional equipment
Barbells
Dumbells
Squat rack
Other
What kind of training do you want to be included in your programme?
*
Weight training
HIIT
Circuits
Cardio
Home
Upper/Lower splits body part splits
full body
Other
How many training sessions a week are you willing to do on this programme?
*
1 per week
2 per week
3 per week
As many as needed to reach my goals
What days/times are you currently available to train during your programme ?
*
6am-9am
9am-12pm
12pm-3pm
3pm-6pm
6pm-9pm
9pm-12am
Not available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How long do you want to spend on each workout on this programme?
*
30 mins
45 mins
1 hour
1+ hours
Other
Is there anything else that could affect your aility to participate in sessions that you need to consider?
*
i.e. holidays, religious obligations, childcare etc.
Is there anything specific you want to be able to achieve in your sessions? Something you want to do that you can't now?
*
i.e. press up, deadlift, pull-up, chin up
Is there anything you DON'T want to do on this programme?
*
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7. Readiness to change
Please rate each category on a scale of 1-5
Daily energy levels
*
1
2
3
4
5
Always Tired
Always wired
1 is Always Tired, 5 is Always wired
Readiness to make changes to your diet and nutrition
*
1
2
3
4
5
I'm not ready yet
I'm ready to change!
1 is I'm not ready yet, 5 is I'm ready to change!
Daily Stress Levels
*
1
2
3
4
5
Always Tired
Always wired
1 is Always Tired, 5 is Always wired
Motivation to be fit and healthy
*
1
2
3
4
5
I'm struggling
I'm ready to go!
1 is I'm struggling, 5 is I'm ready to go!
Readiness to make changes to your current lifestyle and activity levels
*
1
2
3
4
5
I'm not ready yet
I'm ready to change!
1 is I'm not ready yet, 5 is I'm ready to change!
8. Terms & Conditions
Please read the following:
1. Your responsibilities & Informed Consent: a. Disclosure of information - You agree to disclose all health information as requested and keep me updated on any changes to your health. This includes all medical conditions; physical and mental, injuries, allergies, and medication you are taking. b. Accepting potential risks – Informed Consent - During your exercise program, every effort will be made to assure your safety. However, as with any exercise program, there are risks. In volunteering for this program, you agree to assume responsibility for these risks and waive any possibility for personal damage. You also agree that, to your knowledge, you have no limiting physical conditions or disability that would preclude an exercise program. c. Medical Referal - As such, if you do have any limiting physical conditions or disabilities you have consulted with your GP and/or physio in regards to participation in this program, they are aware of it and have advised that participation is acceptable before any physical activity in this program begins. You also understand that I am not a doctor, dietician or physiotherapist and that any advice I offer outside of my qualifications, though optimal, is NOT a replacement for professional advice from experts in that particular field. 2. My commitment to you: a. Confidentiality. All information you give me will be kept in confidence. Your personal details and medical information will not be made available to third parties unless permission to do so is granted by you. b. Recommendations. Using my judgment and experience, I will suggest certain exercises and other lifestyle advice that I believe will help you achieve your personal goals, but if at any time you have specific requests please tell me so I can accommodate them. Where I feel it's appropriate, I will advise that you seek professional advice from experts outside of my qualifications and professional field. 3. Incomplete programmes/unused services: • Expiration policy requires all services be completed within the specified time frame of the proposed start date. Services are void after this period unless otherwise agreed by me. • NO REFUNDS will be issued for any reason, including but not limited to; relocation, illness and unused sessions/services. 4. Testimonial/photo release: a. You hereby RELEASE, WAIVE and FOREVER DISCHARGE any and all claims arising out of, or in connection with, such use by myself, including without limitation any and all claims for libel or invasion or privacy. b. You hereby RELEASE, WAIVE and FOREVER DISCHARGE any and all claims arising out of, or in connection with, such use by myself, including without limitation any and all claims for libel or invasion or privacy. 5. Results: You understand the results of any training programme or coaching course are a combination of exercise, nutrition, adherence to the programme and genetics. Results aren’t guaranteed and your progress depends on your effort and cooperation in and outside of the sessions. 6. Sessions: You have control of the workout and may terminate a particular exercise or workout at any time. Further to this it is your responsibility to inform my me of any symptoms such as fatigue, shortness of breath or chest discomfort. You also agree that I may also terminate a particular exercise or workout at any time if I believe you are not in suitable condition for exercise. 7. Holidays: As part of your programme you are paying for a set number of sessions and holidays will not affect this number. In the event of holidays from participating sides, you will be given time to reschedule sessions to complete before or after planned holidays ASAP. 8. Payment: I operate on a prepay basis for all of my products/services. There payment must be made in advance before any products/services are assigned or appointments confirmed. Some services have payment plan offers and as such the same terms apply.
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9. Confirmation
By signing below you agree to all of the subject matter stated herein and above. You confirm that you are of at least 18 years of age and have the right to agree to all of the above and that all of the information you have given is correct to the best of your knowledge.
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