Fields Force Athletics Consultation Questionnaire

Fields Force Athletics Consultation Questionnaire
Full Name

First NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Age
years
Height
In.
Weight
LBS
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?
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems or previous injuries 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
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do any diseases run in your family?

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

YesNo
Please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

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

12345678910
What following goals best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training? Please be extremely specific.
What is your why? Be really honest with yourself here. Otherwise, you won't be able to stay consistent.

TImeline for achieving your goal.

	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.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

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

MorningMid-DayAfternoonEvening
How often would you like to virtually meet a week?
Please Choose
What are your expectations of me as your Fitness Coach?
ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

Please leave a phone number or email so that I can get in contact with you. Or feel free to email or text me as well. find my contact info on my page. I look forward to working with you!
Phone Number
Please enter a valid phone number.
Email
example@example.com
I AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo
Should be Empty: