Online/168 New Client Setup Questionnaire
All information on this form is confidential and is used for coaching purposes only
Name
First Name
Last Name
Phone Number
Email
example@example.com
Which of the following equipment do you have/are willing to acquire at home?
Dumbbells
Kettlebells
Barbell
Bands with Handles
Long Bands
Thera-Band
Mini-bands
Power Rack/Squat Rack
TRX/Suspension Trainer
Exercise Ball (Stability ball)
Medicine Ball (Soft)
Medicine Ball (hard/bouncy)
Yoga Block
Pushup Handles
Sandbag
Machine (upper body)
Machine (Lower Body)
Smith Machine
Pulley/Cable System (Single)
Pulley/Cable System (Multiple)
Treadmill
Bike/Airbike/Peloton
Rower
Elliptical
Other Pieces (List)
If preferred, add photo of workout space/equipment that will be used for exercise program.
Health & Lifestyle
Yes
No
Do you smoke?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Do you feel pain while doing sports/exercise?
Answer the following on a scale of never (0) to always (5)
Planning my meals for the day/week
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
Eat meals out/at restaurants
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
Eat consistently throughout the week
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
Train consistently
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
Train with intensity/purpose
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
How often can you exercise per week?
Exercise would be considered at least 20 minutes of moderate effort
Please select the best days for you to workout
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please select your preferred time of day to workout
Early Mornings
Mornings
Early Afternoons
Afternoons
Evenings
How long do you prefer to train on average?
20-30 Minutes
30-45 Minutes
45-60 Minutes
60-90 Minutes
It varies depending on activity
What are your goals for training?
Development of Strength/Muscle
Reducing stress
Losing body fat
Increasing energy
Training for an event/specific sports
Other
From these goals, please briefly identify the top 2 and why they're important
(all answers are confidential!)
Please list and explain any and all injuries/restrictions you encounter while exercising. Be as specific as possible with regard to exercises/movements that provoke pain along with the length of the issue.
Submit
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