Powerlifting Coaching Inquiry

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Has a doctor stated you have high blood pressure?*

Have you suffered from either heart disease, stroke, sudden death, elevated cholesterol? *

Are you currently on prescribed medication? Does it effect your training? *

Do you have or have you suffered from diabetes?*

Have you had any blood tests conducted in the past 6 months?Was there anything to be concerned about?

Are you currently seeing any medical specialists atm? Please elaborate.

Are you pregnant or have given birth in the past 6 months?*

Is there anything that hasn’t been mentioned that could potential affect your health and well being in relation to your training program?*

Please list any muscular or joint injuries, aches, limitations or pains.*

How long have you been training for?

Have you followed a structured exercise program before? If so how long ago and what where you doing?

I know most movements and am very confident performing themI know the basic movements and can perform them wellI don't know many movements in the gym and am unsure If I do them wellI am extremely competent and confident in the gym with all movements

How many times per week will you commit to your training program?

What time of the day is the best time to train for you?

List your goals and give a brief description of what they mean to you

When would you like to achieve your results by?

Have you achieved results in the past? What were you doing and how long ago?

Are there any movements or exercises that you enjoy in your training?

Are there any movements or exercises that we need to AVOID in training? If yes please explain why.

Please rate on the scale truthfully (1=Poor to 10=Excellent)

Rows	1	2	3	4	5	6	7	8	9	10
Overall energy levels
Overall stress
Mood
Anxiety
Strength/fitness

How many hours of sleep on average do you get per night

What are the main contributors to your overall stress?

What is your occupation? What are the demands of your role physically and mentally?

How much time and what activities do you do to relax?

Do you have any food allergies or intolerance's?

Select the preferences that apply

Rows	Tried it	Currently doing	No, open to trying	No interest in trying	Dont know
Meat 3 veg
Paleo
Vegetarian
Vegan
High Protein
Macros
Clean Eating
Fasting
Portion Control

Diet Snapshot

Do you:

Rows	Yes	No
Drink Coffee Daily
Use Pre-workout more than 1 x per week
Drink alcohol more than once a week
Smoke ciggarettes
Drink 3L water per day
Drink soft drink regularly

Please answer the following truthfully

Rows	Confident	Somewhat Confident	Not Confident
Im prepared to track my food intake
Im prepared to fill in my training plan
Im prepared to send progress pictures as specified
Im prepared to fill in my tracking sheet
Im prepared to modify my diet
Im prepared to take supplements as necessary
Im prepared to modify my lifestyle habits

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