1:1 Fitness and Wellness Profile

1:1 Fitness and Wellness Profile

Training with Esther / Consultation Form
Hi!

We start our journey together here.
This form is to collect information about you with the purpose of giving me key insights to prepare our sessions together considering your goals and needs.

By filling out this form at least a day before our meeting, we can save 30 minutes! and dedicate ourselves to starting your training.

Please fill out every question as truthfully as you can, and if you have any questions we can discuss it in our first meeting. The information provided is strictly confidential and only I will have access to it.

Thank you for your time.
Esther

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CONTACT DETAILS
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Emergency Contact*
Medical History
Current weight*
Kg
Height*
cm
1. Do you have or have had any of the following?*

High Blood PressureHeart conditionEpilepsy/SeizuresSwollen Ankles/JointsDiabetesNerve damageAsthmaHigh/Low CholesterolAnemiaChest Pains/Breathing DifficultiesArthritis/OsteoporosisHip / Knee replacementCurrently PregnantNone of the Above
If you have ticketed any options, please give details below. (Include all the medication you are taking)*
Do you have any other medical history you feel comfortable disclosing?*
Muscular-Skeletal: Do you have or have had any injury? Please Describe. *
Sports and training History. Do you or did you play any sports? Please describe. *
Hormonal (Women only). Are you still getting your period? How often? / Are you experiencing menopause? Which phase and what kind of symptoms?. Please be as specific as possible.*
Current Nutritional Habits / Example of Daily intake

Include drinks you have also.
Breakfast *
What do you have and at what time?
Morning Tea*
What do you have and at what time?
Lunch*
What do you have and at what time?
Afternoon Tea*
What do you have and at what time?
Dinner*
What do you have and at what time?
Desserts*
What do you have and at what time?
Any Food Intolerances*
Taking any Supplements*
BCAA, Protein shakes, multivitamins etc
Do you drink coffee? Please describe how many coffees a day and how do you drink it. *
Movement Assessment and Goals
What kind of training regime/ style of training have you done or are you currently doing? *
Have you ever follow an exercise program before? If yes or no please describe. *
Do you feel comfortable with Squats, Lunges, Bench Press and Deadlift? Please describe. *
Do you feel comfortable getting up and down the floor?*

YESNO
Do you feel comfortable being on you back/stomach? Please describe. *
What would you rate your current Health and Fitness level? *

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1 is Worst, 10 is Best
Based on your previous answer, What number would you like. to achieve in the next 3 months? *

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1 is Worst, 10 is Best
What activities are you doing at the moment where you don't feel strong, fit, confident? Be as specific as possible. *
What are your 3 main physical goals? From exercises you want to achieve, to activities you want to do, how you want to feel, etc., tell me everything! *
LIFESTYLE AND GOALS
From 1 to 10 (1 being the lowest and 10 the highest) how would you rate your current sleep? *

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10

1 is Worst, 10 is Best
Please describe your sleeping habits. Time to go to bed, wake up, how many hours do you sleep, quality of sleep, etc. *
Do you smoke?*
Yes / No
If so, how many a day?*
10 / 20...
Do you drink alcohol?*
Yes / No - Which type?
If so, how often?*
daily/ weekly/ weekends
From 1 to 10, how would you rate you current stress levels? *

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10

1 is Worst, 10 is Best
What kind of activities do you do to relax and decompress Please describe. *
LASTLY
Describe the 3 main goals you want to achieve by working together. Be as specific as you can. *
How are those goals look like to you? Ex: waking up without aches and pain, play with my kids without discomfort, being able to wear my favourite jeans again, etc. *
Please describe 3 main obstacles that could prevent you from achieving your goals? *
Signature*

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1:1 Fitness and Wellness Profile

CONTACT DETAILS

Medical History

Current Nutritional Habits / Example of Daily intake

Movement Assessment and Goals

LIFESTYLE AND GOALS

LASTLY