Coaching enquiry
Thanks for your interest in coaching! Please fill out the form below and I'll get back to you ASAP
1. Personal Information
Name
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Please Select
Female
Male
Prefer not to say
Height:
*
enter in cm
Weight:
*
enter in kg
Email
*
example@example.com
Contact number
*
-
Country Code
Phone Number
Emergency contact
*
-
Country Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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2. Lifestyle Information
What is your main fitness goal?
*
Give as much detail as possible about your studies
Why is this goal important to you now?
*
Give details of your role and obligations
How long have you been trying to reach this goal?
*
If yes, give as much detail as possible about the days/times you work/study
Training experience level
*
Beginner
Intermediate
Advance
Other
How often do you currently train?
*
Nothing just now
1-2 days a week
3-4 days a week
5+ days a week
Other
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3. Health/Medical Information
Do you have any diagnosed health/medical conditions that I should be made aware of?
*
Yes
No
If you do, please list them here. Be as detailed as you can about, what it is, how it affects you and how you are managing your symptoms
*
Type 'not applicable' if you answered 'No' to the previous question
Have you had any injuries recently or in the past that I should be made aware of?
*
Yes
No
If you do, please list them here. Be as detailed as you can about, what it is, how it affects you and how you are managing your symptoms
*
Type 'not applicable' if you answered 'No' to the previous question
Do you smoke?
*
Yes
No
Occasionally
Other
Do you drink alcohol?
*
Yes
No
Occasionally
Other
How many hours of sleep do you get on average per night?
*
4 hours or less
5-7 hours
8+ hours
I don't know
How many steps on average do you do per day ?
*
less than 3000
3000-5000
5001-8000
80001-9999
1000+
I don't know
How are you tracking your activity ?
*
Fitbit
Apple Watch
Galaxy Gear/Galaxy Active
Other smart watch
Mobile phone step tracker
Other device
Just a guess
I don't know
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4. Your Goals
What is your main reason for taking up this programme?
*
Give as much details as possible about any specific, measurable goals you have
What areas of your health and fitness do you want to focus on?
*
Weight loss
Gain muscle
Confidence
Lifestyle changes
Gain strength
Nutritional guidance
Help to be consistent
Accountability
Training knowledge
Other
Realistically when do you want to achieve your goals?
*
Rows
8 WEEKS
12 WEEKS
16 WEEKS
24 WEEKS
32 WEEKS
40 WEEKS
1 YEAR
1+ YEARS
START
What has stopped you in the past from achieving these goals?
*
Give as much detail as possible
Submit
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