North Rise Remote Coaching Questionnaire

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

years

Height

cm

Weight

KG

What do you do for a living?

Whats the activity level at your job?

Do you follow a regular working schedule, do you work days, afternoon or nights?

How often do you travel?

Please list the physical activities that you participate in outside of the gym and outside of work.:

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

Has anyone of your immediate family developed heart disease before the age of 60?

Do any diseases run in your family?

Do you suffer from diabetes, asthma, high or low blood pressure?

Please list:

What is your goal with your training?

Why?

How often are you able to train per week? how often are you currently training?

What is your competition plan for the next 6-12 months? When do you plan on competing next, do you have any high priority meets in the future?

Goals for next competition?

Personal Bests (list 1-rep PB’s and any other rep-pb’s which might be relevant):

Preferred Techniques for each lift? (ie. low bar, wide grip, sumo)

Current bodyweight? do you plan on staying at this weight?

Have you had a coach in the past or followed a powerlifting program?

What type of equipment do you have access to?

ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

I AGREE TO THE ABOVE TERMS & CONDITIONS!

Signature

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