1:1 Coaching Form

Macstetic Coaching🏋🏻 / Nutritional Tips🥩

Changing lives naturally
Full Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
Inches
Email or Phone Number*
Weight*
lb
Phone callEmailTextMessengerOther
What do you do for a living?*
none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?*
RarelyA few times a yearA few times a monthWeekly
How would you rate the stress of your job?*

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1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown
How would you rate the stress of your lifestyle?*

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1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown
yesno
YesNo
If Yes to the question above, please list reason here.
If you are on any medications not previously mentioned, including multivitamins,please list them here, including how long you have been taking them. Enter none if none.*
If you have any diagnosed health problems not previously mentioned, please list the condition(s) here. Enter none if none.*
Please list any injuries or surgeries you have had in the past five years. Enter none if none.*
YesNo
If yes to the above question, please explain.
Diabetes Type 1Diabetes Type 2AsthmaHigh blood pressureLow blood pressureHeart attackBypass or cardiac surgeryChest discomfort with exertionRapid or runaway heartbeatSkipped heartbeatShortness of breath with or without exerciseFainting or light-headednessPulmonary disease or disorderStrokeHigh cholesterolRecent hospitalizationsOrthopedic problems, including arthritisOther
If yes to any of the above, please explain here.
YesNo
YesNo
YesNo
Head/NeckUpper BackShouldersArm/ElbowWrist/HandsLower BackHips/PelvisThigh/KneesHerniaOther
If yes, please explain.
YesNo
If yes, please explain.
YesNo
If yes, please explain:
Please list any dietary supplements you take here (protein powder, creatine, B12, etc). Enter none if none.*
Please list any allergies you have here. Enter none if none.*
Please rate how you feel your current nutritional habits are*

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1 is I don't worry about what I eat, I just eat whatever, wherever., 10 is I am very conscious of my food choices and eat whole foods fruits, and vegetables, and limit my processed food intake.
Appearance/AestheticsCardiovascular EnduranceFlexibilityHealth (General)Muscular DefinitionMuscular SizeMuscular Strength/PowerSelf-esteem/ConfidenceSpeedSports PerformanceStress ReductionWeight LossPostureOther
What are the top three goals you want to accomplish, in order of importance?*
Lack of motivationTimeSelf ConsciousLack of equipmentLack of ResultsHitting A PlateauMoneyNot knowing where/how to beginOther
How often are you willing to train per week to reach goals?*
YesNo
If yes, what gym?
DumbbellsBarbellsWeight BenchAerobic Machines (treadmill, elliptical, stationary bike, rower, etc)Weight MachinesCable WeightsResistance BandsBosu BallKettlebellsSuspension StrapsPunching BagStability BallPilates ReformerOther equipment?
YesNo
If yes, how many days a week?
How long is each session in minutes?
YesNo
If yes, what sports and how often?
Describe what you expect of me as your fitness coach.*
Please rate your mental readiness to make changes to reach your goal.*

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1 is I am not ready to make any changes. , 10 is I'm ready to make any lifestyle changes to reach my goals!
Please rate your motivational level to do what it takes to reach your goal.*

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1 is I have no motivation to change my life., 10 is I'm ready to make any lifestyle changes to reach my goals!
Need a strong motivator to push you to exerciseYou like to be informed about your program and how it is going to lead you to your goalsLike to try new things if they are effectiveWilling to push past your comfort level to reach your goalsI feel things are really hard I tend to back offNeed to be held accountable for what I am doingBeing sore the day after a workout tells me my workouts are workingOther
YesNo
Fitness Business Name

Informed Consent Form
I, give my consent to participate in the physical fitness evaluation program Macstetic Coaching, conducted by: Connor Macrobert.

Benefits

Participation in a regular program of physical activity has been shown to produce positive changes in a number of organ systmes. These changes include increased work capacity, improved cardiovascular efficiency, and increased muscualr stregnth, flexibility,power and endurance.

Risks

I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains, etc) and the cardiorespiratory system (dizziness, discomfort in breathing, heart attack, etc). I hereby certify I know of no medical problem (except those noted on this form) that would increase my risk of illness and injury as a result of participation in a regular exercise program.

Testing and Evaluation Results

I understand I will undergo initial testing to determine my current physical fitness status. The testing will consist of, in part or in whole, a health, medical, and lifestyle questionairre, a cardiovascular fitness test (bicycle, step, run, walk, or similar), and testing for muscular fitness and body composition.

I further understand such screening is intended to provide The Trainers with essential information used in the development of individual fitness programs. I understnad my individual results will be made available only to me. I also understand the testing is not intended to replace any other medical test or the services of a physician. I will be provided a copy of all test results. I may share the results with whomever I please, including my personal physician.

By signing this consent form, I understand I am personally responsible for my actions during my tenure with The Trainers and I waive the responsibility of this center if I should incur any injury as a result of my negligence.
YesNo
Client Signature*

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It is my responsibility to consult a physician before participating in this or any fitness program and I affirm that I have no medical conditions that would restrict me from participating in any of the Fitness Services.I agree to hold the Fitness Provider, and if applicable, its owners, trainers, and representatives, harmless from any damage, whether tangible or intangible, that may happen to me while participating in the Fitness Services. Such injuries may include, but are not limited to, muscle strains, muscle sprains, muscle spasms, heart attacks, raised blood pressure, and broken, fractured, or dislocated bones.I agree that the Fitness Provider offers the Fitness Services with no guarantee of results. I agree that I am solely responsible to maintain the diet and fitness regime appropriate for my level of health and stamina, and I agree that any results that occur, whether positive or negative, are the effects of my own personal choices.I agree that participation in the Fitness Services is not a replacement for actual medical care, and that if I do experience medical issues, I will contact my doctor immediately.I agree and verify that all of the information that I have given the Fitness Provider and its representatives is accurate, up-to-date, and without the omission of any known medical issues.I agree and verify that If I have omitted any necessary personal information, whether knowingly or unknowingly, I will hold the Fitness Provider harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions.I agree to keep the Fitness Provider apprised of any changes or upcoming changes concerning my physical health and personal information.I understand and agree that it is my responsibility to let the Fitness Provider know if I find myself in any pain or discomfort before, after, or during the Fitness Services.If I do require medical treatment or attention while or after participating in the Fitness Services, I agree that the medical costs are mine and mine alone and hold the Fitness Provider blameless from any charges, fees, or costs that my conditions may incur.
Client Signature*

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Macstetic Coaching🏋🏻 / Nutritional Tips🥩