Coaching Intake Form
Please fill out the following to the best of your ability. This helps me to design a program that will help you achieve your goals!
Please verify that you are human
*
Personal Details:
Full Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Sex
*
Male
Female
Prefer not to say
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Pre-exercise screening
Have you or a blood relative (under 55) suffered from heart disease, stroke, elevated cholesterol or sudden death?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you smoke?
*
Yes
No
Do you have, or have suffered from diabetes?
*
Yes, Type I
Yes, Type II
No
Are you currently taking prescribed medication which will affect exercise?
*
Yes
No
Are you pregnant or have given birth in the last 12 weeks?
*
Yes
No
Do you have, or have had, any injuries involving:
*
Neck
Back
Hips
Knees
Shoulders
Ankles
Wrists
Elbows
N/A
Other
Do you have, or have you suffered from:
*
Epilepsy
Arthritis
Hernia
Asthma
Dizziness/fainting
N/A
Other
Back
Next
Goals and motivation
What are your primary fitness goals?
*
Muscle gain
Change body shape
Movement for mental health
Weight/Fat loss
Rehabilitation
Sports specific
Other
Why are these goals important to you?
*
(Eg. I want to gain muscle because...)
What motivates you to achieve these goals?
*
(Eg. Constant support from my coach will motivate me OR seeing/feeling the process motivates me)
What obstacles or challenges have prevented you from achieving your goals in the past?
*
(Eg. I always start strong for the first 3 weeks, but then lose motivation)
What does success look like for you in this program?
*
Back
Next
Current fitness level and routine
How would you rate your current fitness level?
*
Please Select
Generally unfit with little exercise experience
Generally fit enough to participate in daily activities
I do some exercise on a weekly basis and am ready for a new challenge
I'm quite fit, aerobically and strength wise
I'm very fit and have exercised regularly for more than 12 months
How many days per week do you currently exercise?
*
Describe your current exercise routine:
*
(Eg. Strength training on Monday, Wednesday and Friday, 2km run on Sunday and a Zumba class on Tuesday night)
What exercise equipment do you have access to?
*
Fully equipped gym (if following is included)
Leg press
Hack squat
Leg extension/leg curl
Machine chest press
Cables (including chest fly, lat pulldown and row)
Machine lat pulldown
Machine row
Dumbbells
Barbell
Squat rack
Hip ab/adduction machine
Glute trainer
Boxes
Bench
I don't have access to any of this equipment
What is your current height?
*
What is your current weight?
*
Back
Next
Nutrition and lifestyle
Describe your average day of eating:
*
(Eg. Breakfast - 3x eggs on 2x toast, Snack - yoghurt + fruit, Lunch - burger and fries, etc)
Do you have any dietary restrictions or preferences?
*
How many hours of sleep per night do you get on average?
*
How many days would you like to train?
*
On which days can you train?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Back
Next
Additional information
Do you have any specific preferences or expectations for your training program?
Is there anything else you'd like me to know?
Consent and agreement
By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform my trainer of any changes to my health or fitness
Please enter todays date
*
-
Day
-
Month
Year
Date
Signature
*
Submit
Submit
Should be Empty: