Consultation Form

Personal Information:
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Height (cm's)
Weight (kg's)
Age (years)
Training:
What is your main goal focused around ?

Other
When was the last time you followed a structured training program to achieve your goals?
Have you ever done PTs before and what was overall experience? What is the reason you are moving from your current coach? (for people interested in PTs)
Have you ever followed an online training program ? If yes, please explain for how long and why did you stop ?
Do you have any injuries, list the condition(s).
Do you practice any other activities ?
If yes, what type of activities are these and how many times per week you practice them?
How many steps you conduct per day ?
Nutrition:
How would you rate your current nutrition?

1

2

3

4

5

1 is Worst, 5 is Best
Are you currently on a specific diet plan ?
How many meals you eat per day?
Are you experiencing any stress or motivational problems?
Do you have any food allergies or intolerances? If yes, list below.
Do you take any supplements or vitamins ?
If yes, list below.
Do you have any diagnosed health problems, list the condition(s).
Do you suffer from any of the below conditions?
FEMALE HEALTH & MENSTRUAL CYCLE
Do you currently have a menstrual cycle?
Has your cycle ever become irregular or stopped during dieting, weight loss, or high training volume?
Which best describes your pregnancy, breastfeeding, or conception status?
HORMONAL & METABOLIC HEALTH
Has a qualified healthcare professional formally diagnosed any of the following?

Other
Please share any relevant details about these diagnoses.
Are you currently receiving medical treatment or professional nutrition guidance for these concerns?
PCOS
Is PCOS formally diagnosed or currently being investigated?
Which PCOS-related symptoms affect you most?

Other
Has insulin resistance or impaired glucose regulation been diagnosed?
THYROID HEALTH
Which thyroid diagnosis applies to you?
Do you take prescribed thyroid medication?
If yes, please share the medication and dosage if known.
DIGESTIVE & GUT HEALTH
Do you experience any regular digestive symptoms?
How often do these symptoms occur?
Have you been formally diagnosed with any GI condition?
Have you previously followed a medically recommended elimination diet, low-FODMAP diet, or therapeutic diet?
If yes, please share the duration and any food reintroduction outcome.
Have you currently or previously used weight-loss medication or GLP-1s?
WEIGHT-LOSS MEDICATION & GLP-1 HISTORY
Which GLP-1 / weight-loss medication(s) have you used?
If other, please specify the exact brand or product name.
When did you first start using this product?
How long have you been using it, or how long did you use it?
Are you still using it now?
If you stopped, when did you stop and why?
What was the main reason you started using it?
Please provide any additional context about why you started this medication or product and what outcome you were hoping to achieve.
What was the lowest body weight you reached while using it? (kg)
After stopping, did your weight change? If yes, about how much did you gain or lose?
Have you switched from one GLP-1 / weight-loss medication to another? If yes, which medication did you switch from and to, and why?
MEDICAL & MEDICATION SCREENING
Do you have any diagnosed medical conditions that may affect nutrition, training, recovery, or body-composition goals?
Have blood tests been performed in the last 12 months?
DIETING & WEIGHT HISTORY
How many dieting phases have you had, and roughly how long did they last?
What was your lowest adult body weight? (optional)
Which symptoms, if any, did you experience during dieting?

Other
How would you describe your current relationship with food and dieting?
Do you have a current or previous eating-disorder or disordered-eating history?
FINAL COACHING ASSESSMENT
On a scale of 1 to 10, how ready are you to make consistent training, nutrition, and lifestyle changes?
Which accountability style do you prefer?
Is there anything else about your health, menstrual cycle, digestion, lifestyle, relationship with food, training history, or personal circumstances that would help your coach?
Plan agreement:
What online coaching package would you be interested in? "note: I offer only 3 months plan as this is the most accurate timeline of when clients will start seeing results" :
Please select the date you would like to start your package.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Personal Information:

Training:

Nutrition:

FEMALE HEALTH & MENSTRUAL CYCLE

HORMONAL & METABOLIC HEALTH

PCOS

THYROID HEALTH

DIGESTIVE & GUT HEALTH

WEIGHT-LOSS MEDICATION & GLP-1 HISTORY

MEDICAL & MEDICATION SCREENING

DIETING & WEIGHT HISTORY

FINAL COACHING ASSESSMENT

Plan agreement: