Project Mythology Intake Form

Project Mythology Consultation Questionnaire
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
How did you hear about me?
Best day/time for a phone consultation
Gender

MaleFemale
Date of Birth

MonthDayYear
Age
years
Height
in
Weight
Lbs
What do you do for a living?
Whats the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
Please list:
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special dietCarnivoreOther
Please rate your readiness for change.

12345678910
Which of the following goals best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What does your current diet look like? Please include calories and/or macros if you know them.
What foods do you dislike?
What is your goal with your training?
Why?

TImeline for achieving your goal.

	2mo	4mo	6mo	8mo	10mo	1 YEAR
NOW

Please rate your motivational level to do what it takes for reach your goal.

12345678910
How many days per week do you exercise?

1-23-45-6
Have you trained with a personal trainer before?

YesNo
What kind of training did you do?
At what times during the day do you prefer to train?

MorningMid-DayAfternoonEvening
Are you currently able to commit to investing time, effort and financial resources into achieving your goals with me as a coach?
How often do you want to train per week?
What are your expectations of me as your coach?
Should be Empty:

Project Mythology Consultation Questionnaire