Emily's Fitness Client Consultation Form

1
What’s your first name?* This field is required.Legal First Name
2
What is your preferred name/and nicknames?
3
And your last name?* This field is required.Legal Last Name
4
What are your preferred pronouns?
5
What is your date of birth?* This field is required.
6
And your phone number?* This field is required.
Area Code
Phone Number
7
And your email?* This field is required.
example@example.com
8
What made you enquire about my coaching?
9
What are your main goals you want to achieve with my coaching?
10
How many days a week do you want to exercise?
1 to 2
3 to 4
4 to 5
5 to 6
6 to 7
7+
11
How many days a week do you currently exercise? (In sessions of 30 minutes+)
1 to 2
3 to 4
4 to 5
5 to 6
6 to 7
7+
12
PAR-Q, Physical Activity Readiness Questionnaire, please answer all questions
13
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?* This field is required.
YESNO
14
Do you feel pain in your chest when you do physical activity?* This field is required.
YESNO
15
In the past month, have you had chest pain when you were not doing physical activity?* This field is required.
YESNO
16
Do you lose balance because of dizziness or do you ever lose consciousness?* This field is required.
YESNO
17
Do you have a bone or joint problem (eg:back, knee, hip) that could be made worse by a change in your physical activity?* This field is required.
YESNO
18
Is your doctor currently prescribing medication for your blood pressure or heart condition?* This field is required.
YESNO
19
Do you have any current or past history with any eating disorders or disordered eating?* This field is required.
YESNO
20
Do you know of any other reason why you should not take part in physical activity?* This field is required.
YESNO
21
If yes to any of the above questions, please give details
22
Do you have any other medical/health related issues that I should be aware of? Including any medication
Huge
Large
Normal
Small
Ok
Ok
23
I have read, understood and correct completed this questionnaire and I will inform my coach immediately if there are any changes. I confirm that I am voluntarily engaging in exercise at an acceptable, and I understand that my participation involves a risk of injury, which my coach, Emily Dawkins, is not liable for.* This field is required.
I acceptI don’t accept
24
Your personal preferences:
25
Which coaching package would you like?* This field is required.These are listed on my instagram/Facebook
Please Select
Gold
Silver (Most Popular)
Bronze
Unsure, please help!
26
Where will you be doing your workouts?* This field is required.
A gym
At home (no equipment)
At home (little equipment)
At home (a home gym/lots of equipment)
27
Are there any particular exercises you enjoy?
28
How long do you want your workouts to be?
0-30 minutes
30-45 minutes
45-60 minutes
60-75 minutes
75+ minutes
29
Fitness and exercise is a perfect example of a ‘you get what you give’ relationship. It can take a lot of effort and can take a little while before you start to see results. While I can help to guide you towards your goals, I cannot reach them for you. You will only see results and reach your goals if you are willing to put the effort in and not give up.
I understand and I’m happy to continue
Should be Empty: