Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
-
Country Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height (CM)
*
Weight (KG)
*
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Medical History
Do you have any medical conditions?
*
Yes
No
If yes, please specify
*
Do you know of any reason why you should not participate in physical activity?
*
How would you rate your current health?
*
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Exercise History
Do you currently exercise?
*
Yes, regularly
Yes, but not often
No, but I have previously
Never
If yes, please describe your current exercise routine in detail (inc. how often, what type)
*
How much time are you willing to invest / are able to commit to exercise?
*
1-2 sessions per week
2-3 sessions per week
3-4 sessions per week
4+ sessions per week
Current Lifestyle
On average, many hours of sleep do you get per night?
On average, how many litres of water do you drink per day?
On average, what is your daily step count?
Do you take any supplements? If so, what?
How would you rate your nutrition? Please give as much detail as possible.
*
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Coaching
Have you worked with a coach previously?
*
Yes
No
Why are you interested in Online Coaching?
*
What are you looking for in a Coach?
*
What are your current fitness goals? Please give as much detail as possible.
*
What do you believe is stopping you from reaching your goals?
*
Are you ready to invest time and energy into this process?
*
Yes
Yes, but not yet
No, but I want to
No
Are you able to invest financially into Online Coaching?
*
Yes
No
If yes, how much are you willing to invest per month?
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