NAME
First Name
Last Name
DATE OF BIRTH
-
Month
-
Day
Year
Date
DATE
-
Month
-
Day
Year
Date
Current Weight
Current Height
GENDER
Please Select
Male
Female
N/A
EMAIL
example@example.com
MOBILE PHONE
Please enter a valid phone number.
HOME PHONE
Please enter a valid phone number.
What do you want?
In general, what are your goals? Check all that apply
Lose weight / fat
Improve physical fitness
Get control of eating habits
Gain weight
Look better
Get stronger
Maintain weight
Feel better
Physique competition / modeling
Add muscle
Have more energy and vitality
Improve athletic performance
Improve overall health
Healthy aging
Get off or decrease medications
Other (please specify):
What do you want to change?
Out of all of the changes you’d like to make, which ones feel most important / urgent?
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? If so, what?
Which of those things worked well for you, and why? (Even just a little bit, and even if you might not be doing them right now.)
Which of those things didn’t work well for you, and why not?
Until now, what has blocked you or held you back from changing these things?
What are you doing right now?
Right now, how would you rank your overall eating / nutrition habits?
HORRIBLE
1
2
3
4
5
6
7
8
9
AWESOME!!!
10
1 is HORRIBLE, 10 is AWESOME!!!
Are you regularly active in sports and / or exercise?
Yes
No
If so, approximately how many hours per week?
Fewer than 5 hours
10-14
20 or more
5-9
15-19
What types of sports and / or exercise do you typically do?
Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
Fewer than 5 hours
10-14
20 or more
5-9
15-19
What other types of movement and / or activities do you do?
Where will you be doing the majority of your workouts?
Home gym
Membership style Gym
Hybrid
No equipment - Resistance bands only
Do you have any restrictions on the type of weight lifting exercises you are able to do? (Injuries, surgeries, etc.)
How do you feel overall? Anything I should be aware of?
How ready, willing, and able are you to change?
Right now, on a scale of 1-10:
How READY are you to change your behaviors and habits?
NOT AT ALL
1
2
3
4
5
6
7
8
9
COMPLETELY
10
1 is NOT AT ALL , 10 is COMPLETELY
How ABLE are you to change your behaviors and habits?
NOT AT ALL
1
2
3
4
5
6
7
8
9
COMPLETELY
10
1 is NOT AT ALL , 10 is COMPLETELY
What do you expect?
What do you expect from me as your coach?
Client signature:
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