Snatched Personal Training Questionnaire

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Please list your height?Example: 182cm/75kg/15%
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Has a doctor stated you have high blood pressure?* This field is required.
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Have you suffered from either heart disease, stroke, elevated cholesterol? * This field is required.
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Are you currently on prescribed medication? Does it effect your training? * This field is required.If selected Yes, please elaborate in text box
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Do you have or have you suffered from diabetes?* This field is required.
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Have you had any blood tests conducted in the past 6 months?Was there anything to be concerned about?If selected Yes, please elaborate in text box
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Are you currently seeing any medical specialists atm? Please elaborate.If selected Yes, please elaborate in text box
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Are you pregnant or have given birth in the past 6 months?* This field is required.If selected Yes, please elaborate in text box
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Is there anything that hasn’t been mentioned that could potential affect your health and well being in relation to your training program?* This field is required.If selected Yes, please elaborate in text box. This is not soft tissue and joint related
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Please list any muscular or joint injuries, aches, limitations or pains.* This field is required.Please list date of the incident, any treatment/rehabilitation and if the condition still persists.
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How long have you been training for?
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Have you followed an exercise program before? Have you had a structured program with your workouts set out, rep schemes, rest, exercise order etc.
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How many times per week will you commit to your training program?
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What time of the day is the best time to train for you?
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List your goals and give a brief description of what they mean to youExample. I would like to get to 10% bodyfat and get stronger in my squat
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When would you like to achieve your results by? It is always good to set deadlines.
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Please rate on the scale truthfully (1=Poor to 10=Excellent)The lower the score would indicate you are suffering the most
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Overall energy levels
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Overall stress
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Mood
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Anxiety
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Strength/fitness
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Overall energy levels
Overall stress
Mood
Anxiety
Strength/fitness
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How many hours of sleep on average do you get per night
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What are the main contributors to your overall stress?Examples. job commitments, sleep quality, diet, family commitments etc.
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What is your occupation? What are the demands of your role physically and mentally?
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How much time and what activities do you do to relax?
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What is the time frame between your last meal and your bed time?
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Do you eat breakfast within 30-60 mins upon waking?
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Do you have any food allergies or intolerance's?These are foods that cause allergy like symptoms (bloating, cramps, nausea etc.)
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Select the preferences that apply
Tried it
Currently doing
No, open to trying
No interest in trying
Dont know
Meat 3 veg
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Paleo
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Vegetarian
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Vegan
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High Protein
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Macros
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Clean Eating
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Fasting
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Portion Control
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Meat 3 veg
Paleo
Vegetarian
Vegan
High Protein
Macros
Clean Eating
Fasting
Portion Control
Tried it
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Currently doing
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No, open to trying
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No interest in trying
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Dont know
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Tried it
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Currently doing
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No, open to trying
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No interest in trying
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Dont know
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Tried it
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Currently doing
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No, open to trying
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No interest in trying
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Dont know
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Tried it
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Currently doing
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No, open to trying
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No interest in trying
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Dont know
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Tried it
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Currently doing
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No, open to trying
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No interest in trying
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Tried it
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Currently doing
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No interest in trying
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Tried it
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Currently doing
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No interest in trying
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Tried it
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Currently doing
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No interest in trying
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Currently doing
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Diet SnapshotPlease provide a description of a days food and fluid from Meal 1 to Meal "x"
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Do you:
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No
Drink Coffee Daily
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Use Pre-workout more than 1 x per week
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Drink alcohol more than once a week
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Smoke ciggarettes
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Drink 3L water per day
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Drink soft drink regularly
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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
Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Do you suffer from:
Yes
No
Joint Pain
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Digestive Issues
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Lethargy
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Bloating
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Bad Menstrual Periods
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Joint Pain
Digestive Issues
Lethargy
Bloating
Bad Menstrual Periods
Yes
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No
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Yes
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No
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Yes
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No
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Please answer the following truthfully
Confident
Somewhat Confident
Not Confident
Im prepared to track my food intake
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Im prepared to fill in my training plan
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Im prepared to send progress pictures as specified
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Im prepared to fill in my tracking sheet
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Im prepared to modify my diet
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Im prepared to take supplements as necessary
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Im prepared to modify my lifestyle habits
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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
Confident
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Not Confident
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Confident
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Somewhat Confident
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Not Confident
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Confident
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Somewhat Confident
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Not Confident
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Confident
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Somewhat Confident
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Not Confident
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Confident
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Somewhat Confident
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Not Confident
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Confident
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Somewhat Confident
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Not Confident
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Confident
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Somewhat Confident
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Snatched will make various efforts to minimize any potential risks. However, you must be aware that exercise has some potential side effects and risks. It is possible throughout the exercise assessment, training sessions, or the program that you may experience abnormal blood pressure, irregular heart rhythm, dehydration, fainting, and/or dizziness. It is also possible that you might seriously injure yourself from the use of exercise equipment, failure of exercise equipment, tripping or falling, or other hazards associated with equipment, moving around while exercising, and your surroundings. In very rare circumstances, it is possible that exercise can cause heart attack, stroke or death. It is extremely important that any physical or other symptoms that you experience whilst participating in the program are explained to Stacie, even if you feel that they might not be important. It is also important that you tell your Snatched trainer any information you possess about your health status, or changes to your health during the course of your program, especially those that relate to heart problems including shortness of breath, Informed Consent and Release of Information for Participation in Exercise pain, pressure, tightness or heaviness in the chest, neck, back, jaw, calf area and/or arms. By telling your trainer this information you are minimising your risk or injury, complications and death. It is expected that you will tell your Snatched trainer all medications you use, begin to use or cease using (including non-prescription) prior to participation in your initial or regular training sessions. It is also expected that any short term changes to your usual medication regime are reported to your Snatched trainer (e.g. forgetting to take your medication one morning). I understand all of the information and instructions outlined in this informed consent, have had time to discuss any concerns with a health professional, and considering this, agree to participate in a Snatched by Stacie program at my own risk. I also agree to release and indemnify Snatched by Stacie from or against any actions or claims arising from any injury, loss, damage or death caused to me. I also give permission for Snatched by Stacie to use my image/name in the of the above promotional outlets listed. I hereby consent to voluntarily engage in the exercise program considering the above information. I understand what is expected of me and the risks and procedures associated with this program. After fully reading this document I voluntarily consent to participate in the exercise program.* This field is required.
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Signature Required By signing this document you are stating you have read all the questions and content and have answered truthfully
Clear
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Do you have any questions or concerns? (if so please email snatchedbystacie@gmail.com)
yes or no
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Thank You MessageYou’re all set. Thank you for booking your session. I’ll review your form and email you soon to confirm your time and next steps. Make sure to check your inbox for my message. I can’t wait to train with you and help you get one step closer to your goal.
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