Client questionaire

Client Questionaire
Client Info

General
Name

First NameLast Name
DOB
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
Employer & Occupation
Body Weight & Height
Body Fat %
Type N/A if unknown
Goal
Program
Recreational
Do you partake in any recreational activities? (If yes, please explain.)
Golfing, 5ks, etc.
Do you have any additional hobbies? (If yes, please explain.)
Reading, video games, etc.
Medical history
Have you gotten blood work done within the last 6 months?
Are you on birth control? (FEMALES ONLY)
Do you smoke? (If yes, how often?)
Do you drink alcohol? (If yes, how often?)
Have you ever had any injuries or chronic pain? (If yes, please explain.)
Have you ever had any surgeries? (If yes, please explain.)
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? (If yes, please explain.)
Are you currently taking any medication? (If yes, please explain.)
Reason and name of medication
Food allergies/ Dietary Restrictions
Type N/A if none
How do you feel about your nutritional habits?
Have you ever worked with a coach in the past?
Do you or have you ever followed a dietary plan?
Are you able to/willing to eat 5-6 whole meals a day? (If no, please explain why)
Are you able to drink protein powder? (If yes, please list brand)
If no brand is listed, one will be recommended to you.
Daily Meals
Example: 7:30-oatmeal 10am-chicken and rice 12pm- salmon salad 2pm-steak bowl 7pm-protein shake
Daily Activity
Example: 7am-wake up 9am-work 5pm-off 6pm-train 9pm-sleep
Current Cardio
Example: 4x30min weekly
Activity Level
Training Level
Training Location
Body parts you'd like to bring up
Carbs
List carb sources you prefer on your plan
Protein
List protein sources you prefer on your plan
Fats
List fat sources you prefer on your plan

Coheirs Nutrition POLICY
- Coheirsnutrition has the right to refuse service to anyone.
- All programs are NON-TRANSFERABLE.
- All payments to Coheirsnutrition are NON-REFUNDABLE and NON-TRANSFERABLE.
- All cancellations are NON-TRANSFERABLE.
- All payments via invoice and/or paypal have a 5% tax fee.
- Clients will receive their custom plan/program after all documents have been submitted and payment has been made.
- Coheirsnutrition has the right to terminate a program, at ANY time, with no refund, if a client fails to conduct themselves in an appropriate manner.
- Coheirsnutrition has the right to terminate a program, at ANY time, with no refund, if a client fails to submit check-ins for three(3) consecutive weeks.
By signing here, I acknowledge that I have thoroughly read and agree to Coheirs Nutrition's policy above.

Client Photos

Please submit photos of front, side and back with good lighting (full body if possible)
Please submit initial photos for progress of front, side and back. Preferably full body in good lighting.

Women attire: Sports bra and spandex shorts

Men: Boxer shorts or briefs, gym attire shorts

All photos and information is CONFIDENTIAL and will not be posted without consent.
Please submit initial check in photos here

Cancelof
Client consent for photos
By signing here, I acknowledge that all information is correct and accurate to the best of my knowledge and I agree to Coheirs Nutrition's Terms and Conditions and Policy
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Client Questionaire

Client Info

Recreational

Medical history

Coheirs Nutrition POLICY

Client Photos