Coaching In-take

Full Name*

First NameLast Name

Date of Birth*

MonthDayYear

Email*

example@example.com

How did you hear about me?

Phone Number

Area CodePhone Number

Age

years

Height

cm

Weight

KG

What do you do for a living?

Little /No Movement (Desk Job)Moderate (light activity such as steps or on your feet)High (heavy labor, very active)Other

Please add any details relevant to this question here:

Do you follow a regular working schedule, do you work days, afternoon or nights?

Please list the physical activities that you participate in outside of the gym and outside of work:

Daily Routine: Please list wake up times/ bed time, how much sleep you get on average, general stress levels etc:

If you have any diagnosed health problems list the condition(s). Please elaborate these where required:

If you are on any medications, please list them/ any additional therapies that need to be taken into consideration:

If you have any injuries, please list them:

Are you experiencing any stresses or motivational problems? Please elaborate:

YesNo

if yes please list:

YesNo

Please explain your diet, and be as honest as possible. List any foods you have been eating or if you have been following a diet, please explain in detail:

What are your current calories (if known) and current macro's (carbohydrates, fats & proteins if known):

Are you taking any supplements currently/ have you in the past? Please list:

How much caffeine do you consume on daily basis?

Do you have any dietary requirements, food allergies or intolerances?

What are foods you really enjoy, digest well, and make you feel good?

What foods do you dislike/ make you feel bloated or uncomfortable?

Alcohol/ recreational drugs: Do you drink, how often, and do you have an issue with taking a break from this where required to achieve your goals?

How many months/years have you been training in the gym for/ are you a beginner?

Tell me about your goals:

Tell me what makes these important to you:

Please tell me of any obstacles you feel you have faced with fitness in the past, and any fears you have around eating or training if any:

Cardio: What cardio if any are you doing and how often?

Timeline you would like to achieve your smaller goals in:

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?

YesNo

If yes what kind of training did you do:

MorningMid-DayAfternoonEvening

What are your expectations from me as a coach?

Please list anything else important that you think important I know as a coach:

By agreeing to this, I agree the information I have provided is true and I have let my coach know of any injuries, medications or health concerns that are related to my training.

YesNo