Online Coaching Client Sign Up Form
Please answer the following questions fully and honestly so that I can support you during your sessions and create the right blend of movements to suit your abilities and fitness and also ensure you exercise safely with consideration of any health challenges you may have. If you are in any way concerned about your health, please contact your GP for medical clearance before beginning a new workout regime.
Full Name
First Name
Last Name
Mobile Number
Home Address (or address of where you will be doing the online sessions)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
What is your biggest challenge when it comes to your daily movement?
Lack of time
No motivation
Low energy
Physical pain
Not sure what exercise I should do
Don't enjoy exercise
Chronic / Terminal illness
Other
What do you currently do on a weekly or daily basis to move your body? Walk? Swim? Play sports? Etc….
What's your overall goal, where would you like your fitness & body to be 1 year from now?
Has your doctor ever said you have a heart condition & that you should only perform physical activity recommended by a doctor?
Please Select
Yes
No
Do you feel pain in your chest when performing physical activity?
Please Select
Yes
No
Have you experienced chest pain when NOT performing physical activity in the last month?
Please Select
Yes
No
Do you lose your balance because of dizziness or have you lost consciousness recently?
Please Select
Yes
No
Do you have any bone or joint problems such as arthritis, which could be aggravated through physical activity?
Please Select
Yes
No
If you answered yes please provide more details below:
Is your doctor currently prescribing you medication for high blood pressure or a heart condition?
Please Select
Yes
No
If yes please provide details:
Do you currently exercise on a regular basis? 2-4 times per week?
Please Select
Yes
No
Is there any reason why you should not participate in physical activity?
Please Select
Yes
No
Please provide details of any injuries past or current that I need to be aware of that may impact your movement?
Please provide a next of Kin
First Name
Last Name
Next of Kin Mobile Number
Please enter a valid phone number.
Please use this field to tell me anything else you’d like me to know about you, your wellbeing, your fitness, or your life….
Should your health change, please inform me immediately so I can adjust your movement plan accordingly. Please sign below to confirm you have read, understood & accurately completed this form. And that you confirm you are voluntarily engaging in an acceptable level of exercise that will be closely supervised online by a qualified trainer and that participation involves an element of risk of injury should you not follow instructions and guidelines given. Thank you.
Date of Completion
-
Month
-
Day
Year
Date
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