Coach_Mel_JvN
Online coaching form . Please complete all fields
Name
First Name
Last Name
Date
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Month
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Day
Year
Date
Occupation
Your date of birth
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Month
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Day
Year
Date
New or returning client?
Your age
Where are you from ?
Where did you hear from me?
Tell me about your goals
Are you interested in
Meal plan R1250
Training plan R1050
Meals and training R1800
Macros calculations R750
Other. Please email
6 weeks Reset & Rebuild
How long would you like to use my services? Please respect the 2 weeks cancellation policy.
One month only
Longer
Are you ready to make a positive change in your current lifestyle? What do YOU think needs to change?
Your height
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Current weight
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Waist in centimeters
Hips in centimeters
Do you know your current bodyfat ?
Are there any foods that does not react well with you? Allergy test or experience?
Are there other foods you would rather omit from your plan. Indicate please
Do you take milk in your coffee/tea?
Are you on any prescription medication?
Have you had any tests done for hormones/ diabetes/ thyroid etc
What is your diet history like? What was the outcome?
Give an example of a normal day’s meals ( be very honest) Use details. Do you snack after dinner?
Do you, or have you ever tracked macros? Rate your ability out of 5 ( please note, you don't have to track macros to follow my program)
Indicate if you will be training at home or gym. If at home, please write down available equipment
Are you currently exercising? What are you doing? Cardio or weight training?
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Average squat weight
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Can you do pushups
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How many days do you realistically have available for training per week? Time per session?
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How would you describe your fitness level? Beginner / Intermediate/ Advanced
What time do you exercise and do you eat something beforehand
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Any recent injuries that I need to be aware of?
Are you postpartum? How old is your youngest child?
Are you breastfeeding?
Do you have Diastasis Recti that you are aware of. ( postpartum only)
Remember to send a front, back and side picture via email. Have you sent it?
Your pictures are confidential and will never be shared on any platform without consent
Have you made and sent a proof of payment to melissajvn1986@gmail.com?
M Jansensen van Nieuwenhuizen. ABSA Cheque account 4066026618 . Email me for more payment information.
Your email address please
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