Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number in this format (drop the zero) 7539101013
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Age (or age this year if your birthday has not passed)
*
Your Height in CM
*
Your Weight in KG
*
Have you had any operations in the last 2 years and if so please provide details below.
*
Do you have any injuries and/or on any prescriptive medication?
*
Your Relationship Status
*
Single
Married
Divorced
Widower
Seeing Someone (Not Living With Them)
Seeing Someone (Living With Them)
Please tick all of the below boxes which apply to you
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Suffered from Eating Disorders In The Past
Given Birth in the last 6 - 12 Months
Peri-Menopausal - Undiagnosed by GP
Currently Breastfeeding
Peri-Menopausal - Diagnosed by GP
Menopause - 12 Consecutive Months of No Period
None of the above apply to me
Tick All Boxes Which Best Describes Your Life Right Now
*
Parent - Primary Carer
Parent - Not Primary Carer
Given Birth in the Last 6 - 12 Months
Going Through Fertility Treatment
Trying To Get Pregnant
I am the Partner of someone Trying To Get Pregnant
I am the Partner of someone Going Through Fertility Treatment
Children Under 12 Years of Age
Children Over the Age of 12
My Children Are Grown Up & Non Dependent on Me
None of the Above Applies To Me
Single
Dating
If you have given birth in the last 6 to 12 months please provide the following information in the box below. 1. What type of birth did you have? 2. Were there any complications? 3. Has your GP stated you are fit to return to exercise? 4. Are you breast feeding?
Please Describe Your Working Life (Tick All Which Apply)
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In Full or Part Time Education
Juggling a Full Time Job and Parenting
Juggling a Full Time Job, Parenting and Studying
Juggling a Part Time Job and Parenting
Juggling a Part Time Job, Parenting and Studying
I work Full Time
I work Part Time (Less than 25 Hours Per Week)
I do shift work
I work abroad on a rota
I am a Stay at Home Parent
I am un-employed
I am registered disabled
I am on Maternity Leave
Other
If you have a job please enter your profession.
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How Would You Describe Your Stress Levels
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Low; I rarely suffer from stress on a weekly basis
Moderate; A couple of times a week I feel stressed due to Work / Family / Personal reasons - I can handle this most weeks.
High; Daily Stresses which I struggle to cope with or control - Stressful Job, Worrier, Spinning Multiple Plates
If you answered Moderate or High please use this box to explain, stress has a significant impact on health and particularly when it comes to weight loss.
On average how much hours of sleep do you get per night?
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How would you describe your day-to-day activity
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Sedentary; Spend most of the day inactive (desk shop, cashier, delivery driver etc)
Moderately Active; Low Intensity (hairdresser, shelf stacker, stay at home parent etc)
Active; Moderate Intensity (Gym Instructor, Dog Walker, Home Help, Nurse)
Very Active; (Class Instructor, Builder, Joiner etc)
The above diagram shows the 3 types of body composition. Please tick which body composition matches you best physically and by trait.
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Ectomorph; Tall, Slim, Fast Metabolism, Long Limbs, Loses Weight Easily, Finds it Difficult to build Muscle or show Lean Muscle Tone.
Mesomorph; Low Bodyfat, Hour Glass Figure, Toned, Muscular and/or finds it easy to gain muscle and loose weight.
Endomorph; Softer Body with Curves, Wide Waist, Hips and Bones, Weight gain is usually in lower body and abdomen, higher bodyfat with more muscle. Struggles to lose bodyfat.
I am a blend of Ectomorph and Mesomorph
I am a blend of Mesomorph and Endomorph
How Would You Describe Your Fitness Level & Exercise Consistency
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Low; I rarely exercise, I don't exercise regularly and/or don't exercise at all
Moderate; I exercise 2 to 3 times a week, I don't push myself and work within my limits
Good; I exercise 3 times or more per week
Great; I exercise 3 times or more per week, and can push myself comfortably.
Excellent; I exercise 4 times or more per week, can push myself beyond limits and strive for improvement weekly.
What type of exercise do you currently undertake (e.g football, cardio classes, weight training etc) the more information the better!!!
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Have you ever worked with a Gym Based Personal Trainer or another Online Coach? and how did you get on / think of the program (please provide as much detail as possible)
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Which Type of Exercise Program would you prefer if you were to work with us?
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Please Select
Gym Only
Home Workouts Only
A 50/50 Split of Gym & Home
We build our home workouts using the following equipment list, please tick all the equipment you currently have or are happy to purchase to ensure the BEST RESULTS possible on plan. Please note the items with an asterixis * are optional but a great investment for those planning to workout at home long term.
A Pack of 3 Fabric Resistance Bands (Bootay Bands) approx £5-£10
A Small Pilate Ball approx £5
A Bag of Resistance Bands with Handles approx £10-£15
Adjustable Weight Stacked Dumbbells approx £20
A Kettlebell 8 / 10 / 12kg (one kettlebell) approx £10 - £12
A Body Pump Bar & Weights (approx £60 - £80) - * OPTIONAL
A Pair of 3kg Dumbbells
A Suspension Trainer / TRX (approx £15 - £100) - * OPTIONAL
If you have any other equipment at home and are planning on embarking on a home workout plan or gym/home blend please list all your equipment below.
*
Are there any exercises which causes you problems (niggles, difficulty etc)? please provide an explanation why...
*
What Fitness Goal Would You Like to Achieve On Plan? (try to be specific e.g.. I would like to learn how to weight train and double my strength by 50%)
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How Would You Best Describe Your Nutritional Awareness / Experience (please tick all boxes which apply)
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None
I have a basic understanding of what good nutrition looks like
I have a good understanding of what good nutrition looks like
I have a great understanding of what good nutrition looks like
I have never tracked my food before
I have tracked calories in the past
I have tracked calories and protein in the past
I have tracked full macros (protein, carbs and fat) in the past
Tick All The Boxes which best describes your DIET on an average week
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My daily diet contains around 50% Good Quality Food Sources
My daily diet contains over 80% Good Quality Food Sources
I under eat
I over eat
I am good Monday to Thursday, then it all goes abit Pete Tong over the weekend
I consume too much convenience food on a daily basis
I eat out 3 to 5 times per week
I eat very clean and healthy, my diet is primarily whole foods
I consume 1 to 2 Glasses of Wine / Beer or Spirits Approx 2-3 Units Weekly
I consume a Bottle of Wine, or 3 to 5 Beer or Spirits 5 Units Plus Weekly
I drink alcohol once a month or just for social events
Do you have any food allergies / intolerances and are you Vegan / Vegetarian or Pescatarian - please provide details
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DAY 1 FOOD DIARY (Estimated Quantities)
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DAY 2 FOOD DIARY (Estimated Quantities)
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DAY 3 FOOD DIARY (Estimated Quantities)
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What Nutrition Goal would you like to achieve on plan?
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What do you believe your excuses that may challenge you on plan?
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What Is Your Why for changing your lifestyle and/or for picking the goals you wish to achieve?
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If you were referred to Fit With Lainey by a past or current client please enter their name below.
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Is there anything else you would like to share with us that you feel may be important if we work together to help support your plan build?
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My Online Coaching Plans are delivered using Google Sheets, which is similar to an Excel Spreadsheet The Sheet is extremely user friendly and you will be provided a demonstration video which shows you how to use the tool. If you are not technology savvy this may not be the right coaching plan for you. I am unable to support people who need me to teach them how to use this tool. I am happy to send the demonstration video to prospective clients in advance of them making a decision to work with me or not.
I am technology savvy
I am not the best with technology but will be fine if there is a tutorial video
I am not good at technology but have a partner/friend who will help me
I am unsure if I will be able to use the tool and would like to see it as part of my feedback.
Please use this box to ask any further questions you may have.
*
We recommend emailing photos alongside your questionnaire to help us provide accurate feedback fitwithlainey@gmail.com. If you are unable to provide photos at this point in time this is fine, but photos will be required prior to plan build.
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