Coaching Consultation Questionnaire
Full Name
*
First Name
Last Name
Gender
Male
Female
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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Day
Please select a year
2026
2025
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Year
Age
*
years
Height
*
In
Weight
*
LB
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/ school schedule, do you work days, afternoon or nights?
*
How often do you travel?
Rarely
A few times a year
A few times a month
Weekly
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?
Yes
No
Do any diseases run in your family?
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
Please list:
Are you a current cigarette smoker?
Yes
No
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
TImeline for achieving your goal.
Rows
8 WKS
16 WKS
24 WKS
32 WKS
40 WKS
1 YEAR
NOW
How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.
1
2
3
4
5
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7
8
9
10
What are your goals? Be specific
*
Why?
Have you had a coach before?
Yes
No
Outside factors that could affect training
*
What are your expectations for me as a coach?
At what times during the day would you prefer to train?
Morning
Mid-Day
Afternoon
Evening
Submit
Should be Empty: