Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Please list your height (in cm's), weight (kg's) and body fat percentage (if known)
Has a doctor stated you have high blood pressure?
*
Have you suffered from either heart disease, stroke, sudden death, elevated cholesterol?
*
Are you currently on prescribed medication? Does it effect your training?
*
Do you have or have you suffered from diabetes?
*
Have you had any blood tests conducted in the past 6 months?Was there anything to be concerned about?
Are you currently seeing any medical specialists atm? Please elaborate.
Are you pregnant or have given birth in the past 6 months?
*
Is there anything that hasn’t been mentioned that could potential affect your health and well being in relation to your training program?
*
Please list any muscular or joint injuries, aches, limitations or pains.
*
How long have you been training for?
Have you followed an exercise program before?
What are your strongest lifts in those movements?
How many times per week will you commit to your training program?
What time of the day is the best time to train for you?
List your goals and give a brief description of what they mean to you
When would you like to achieve your results by?
Please rate on the scale truthfully (1=Poor to 10=Excellent)
Rows
1
2
3
4
5
6
7
8
9
10
Overall energy levels
Overall stress
Mood
Anxiety
Strength/fitness
How many hours of sleep on average do you get per night
What are the main contributors to your overall stress?
What is your occupation? What are the demands of your role physically and mentally?
How much time and what activities do you do to relax?
What is the time frame between your last meal and your bed time?
Do you eat breakfast within 30-60 mins upon waking?
Do you have any food allergies or intolerance's?
Select the preferences that apply
Rows
Tried it
Currently doing
No, open to trying
No interest in trying
Dont know
Meat 3 veg
Paleo
Vegetarian
Vegan
High Protein
Macros
Clean Eating
Fasting
Portion Control
Diet Snapshot
Do you:
Rows
Yes
No
Drink Coffee Daily
Use Pre-workout more than 1 x per week
Drink alcohol more than once a week
Smoke ciggarettes
Drink 3L water per day
Drink soft drink regularly
Do you suffer from:
Rows
Yes
No
Joint Pain
Digestive Issues
Lethargy
Bloating
Bad Menstrual Periods
Please answer the following truthfully
Rows
Confident
Somewhat Confident
Not Confident
Im prepared to track my food intake
Im prepared to fill in my training plan
Im prepared to send progress pictures as specified
Im prepared to fill in my tracking sheet
Im prepared to modify my diet
Im prepared to take supplements as necessary
Im prepared to modify my lifestyle habits
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