NXT LVLPERFORMANCE
REDEFINE YOUR LIMITS
CLIENT INTAKE & PRE-EXERCISESCREENING
(Universal - Online, In-Person Coaching & Challenges)
Please complete these forms honestly and thoroughly.
Your answers help ensure your training is safe, effective, and appropriately
programmed.
CLIENT DETAILS
Full Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Emergency Contact Name & Phone:
*
Coaching Type (tick all that apply):
*
Transformation Challenge
Online Coaching
In-Person Coaching
Hybrid (Online + In-Person)
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PRE-EXERCISE SCREENING (HEALTH & SAFETY)
Medical History
Have you ever been diagnosed with or do you currently have any of the
following?
(Tick all that apply)
Medical Conditions
*
Heart condition
High blood pressure
Diabetes
Asthma or breathing conditions
Joint issues (knees, hips, shoulders, spine)
Chronic pain
Pregnancy / Postnatal
Hernia
Neurological condition
None of the above
Other
If yes, provide details (condition, limitations, date diagnosed):
Injuries & Physical Limitations
Do you currently have, or have you previously had, any injuries or physical limitations that may affect training?
*
No
Yes
If yes, please list below
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Medications
Are you currently taking any medications that may affect exercise or physical performance?
*
No
Yes
If yes, please list below
Medical Advice
Have you ever been advised by a medical professional to avoid or limit physical activity?
*
No
Yes
If yes, Explain Why
I understand it is my responsibility to seek medical clearance if required.
LIFESTYLE & READINESS
Average sleep per night:
*
<5 hrs
5-6 hrs
6-7 hrs
7-8+ hrs
Daily stress level (1 = low, 5 = very high):
*
1
2
3
4
5
Occupation:
*
Current training experience:
*
Beginner
Returning after break
Intermediate
Advanced
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Nutrition & Lifestyle
On average, how many meals do you eat per day?
*
Do you have any dietary restrictions (vegan, allergies, etc.)?
How many hours of sleep do you get per night?
*
How would you rate your daily energy levels? (1 = low, 10 = high)
*
Do you smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
No
If yes, how often?
GOALS & MOTIVATION
Primary fitness goals? Be specific (Build lean muscle, Loose Body fat, Lean glute muscle growth etc)
*
Lifestyle and mentality goals? (Build discipline, create healthier habits, Build consistency etc)
*
Why are these goals important to you?
*
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What does success look like for you in the next 3-6 months?
*
Mindset & Support
What challenges have held you back in the past?
*
How committed are you to achieving your goals? (1-10)
*
Do you have any support system (partner, friends, community)?
*
Yes
No
PROGRAMMING PREFERENCES
Availability
Preferred training days (List all that apply):
*
Amount of sessions per week you can realistically commit to:
*
Preferred session length:
*
Exercise Preferences
Exercises you enjoy:
Exercises you dislike or want limited:
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Exercises you cannot perform due to injury, pain, or confidence:
Equipment Access
Primary training location:
*
Commercial gym
Home gym
Home (limited equipment)
List equipment available (if training from home):
By signing and submitting this form, I acknowledge that:
All information I have provided is accurate and complete.
I accept full responsibility for my health and safety.
I have read and understood all sections of this document.
Date:
*
-
Month
-
Day
Year
Date
Signature:
*
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