Online Coaching Questionnaire

Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age*
Years
Height*
(Ft)' (in)"
Weight*
Lbs
What do you do for a living?*
What is your activity level at your job?*

None (seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule? (i.e. Do you work days, afternoon or nights?)*
How often do you travel?*

RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work.*
If you have any diagnosed health problems/Allergies, list the condition(s).
If you are on any medications, please list them (optional).
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury(optional)?
Are you experiencing any stresses or motivational problems?*

YesNo
Do any diseases run in your family?*

YesNo
Are you a current cigarette smoker?*

YesNo
Your current diet could be best characterized as:*

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Which of the following goals best align with your goals?*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?*
Why?*
How often during the week are you willing to train to reach your goal? (i.e. 3-5, 4-6, 5-7, etc.)*
Please rate your motivational level to do what it takes for reach your goal.*

12345678910
Are you currently exercising regularly (at least 3x per week)?*

YesNo
Have you trained with an online coach before?*

YesNo
If yes what kind of training did you do:
At what times during the day would you prefer to train?*

MorningMid-DayAfternoonEvening
What are your expectations of me as your Online Coach?*
Are you currently in a financial position to invest in yourself with coaching?*

YesNo, I do not have the budget to invest in myself at this time.Maybe...My budget is tight. If I know I will see progress and get the results I'm looking for, I am willing to invest in myself.
Email*
example@example.com
Phone Number

Area CodePhone Number
* All the information on this form is correct 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.*

YesNo
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