Lifestyle coaching application

Lifestyle coaching application
Full Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
ft. in.
Weight*
lb.
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
Please list any physical activities that you participate in outside of the gym and outside of work:*
If you have any diagnosed health problems list the condition(s).*
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, past injuries, or past surgeries please list them.*
What additional therapies are being undertaken for the given injury?
YesNo
YesNo
YesNo
YesNo
Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Describe a day of your eating habits: (ex. 2 home made meals per day, one regular soda, one meal from fast food.)*
Improved health and lifestyleImproved enduranceIncreased strengthIncreased muscle massFat lossWeight loss
Why do you want to reach these goals?*
How often are you willing to train a week to reach your goals?*
Commercial gymHome gym with heavy and light dumbbellsAt home with little to no equipment
YesNo
What type of training did you do?
Do you have any other experience with structured exercise, weightlifting, or other sports? If so, list them. *
YesNo
Should be Empty: