Dani Coaching Application Form

Tough Cookie 1-on-1 Online Coaching Form

With Dani- The Tough Cookie
Full Name*

First NameLast Name
Email*
example@example.com
Where are you from?
Phone Number*

Area CodePhone Number
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
Weight*
LBS
Why do you want to work with me? Was there a specific thing you were drawn too?
Part 2. Lifestyle Information
What do you do for a living?*
What's the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
What is your work schedule like? (Days, Evenings, Shift etc)
How does your work effect your eating habits?
How stressful is your work?
Do you have any kids? If yes, how do they affect your eating habits?
If in a relationship. Is your significant other supportive of you investing time and money into your health?
What does a "good" day of eating look like (in detail from waking to sleep):
What does a "bad" day of eating look like (in detail from waking to sleep):
Out of 7 days in a week- How often do you have a good day vs a bad day of eating?
Do you get cravings? If yes, when? What do you eat?
How often do you eat out?
Please list foods you enjoy, digest well, and like as well as foods you DO NOT like (This will help us determine your food plan and/or macro set up)
Anything else we need to know about in regards to your eating or foods? Allergies or food intolerances?
Part 3. Medical and health information
If you have any diagnosed health problem or eating disorders? Please list the condition(s).
If you are on medications, please list them below:
If you have any injuries, please list them.
What therapies are being undertaken for the given injury?
Are you a current smoker?

YesNo
Do you currently track your Macros?

YesNoOther
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special dietOther
What types of diets/programs have you tried in the past? How did they go? What did you like and dislike?
Part 4. Goals
If you change nothing at all and keep doing what you have been doing, where do you see yourself being in the next few years? How do you feel about that?*
Please rate your readiness for change. (1 being not at all ready and 10 being 100% ready)

12345678910
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
What do you think you need from a program and our coaches to ensure you not only achieve your goal but maintain it?
My signature program is 16 weeks long. Are you willing to invest time and energy to reach your goal in this timeline?

YesNo
Are you currently exercising regularly (at least 3x per week)?

YesNo
If yes, what kind of exercise are you doing?
If no, what kind of exercise have you done in the past?
Are you willing to train at a gym? If not, what equipment or facilities do you have access to?
Out of 7 days, how many days a week are you willing to train/go to gym/be active a week to reach your goal?
What do you think has stood in your way of successfully achieving your goal and maintaining it?
Have you every hired a personal trainer or coach before?

YesNo
Is there anything else we need to know to ensure we build you the best program to ensure you not only achieve your goals but maintain them?
Please attach a FRONT photo of your current physique:
Please attach a BACK photo of your current physique:
Did someone refer you to me? If so, who?
Should be Empty:

Tough Cookie 1-on-1 Online Coaching Form

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals