Coaching Registration Form
Client Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Please enter your occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
Do you have or had any of the following health/medical conditions?
Chest Pain or Heart Condition
Stroke
Diabetes
High Blood Pressure
Low Blood Pressure
High Cholesterol
Does anyone in your family below the age of 55 have any of the above?
Asthma
Arthritis
Other (Please Specify)
Please specify any other health conditions not previously mentioned.
If yes to any of the above, please describe:
Please provide any relevant information regarding your health condition/s.
Other health related questions:
Have you been pregnant in the last 3 months?
Do you have Asthma?
Do you have Arthritis
Do you smoke?
Have you had any surgical procedures that may affect your ability to exercise?
Do you ever feel dizzy or faint?
Do you have any chronic conditions or illness?
Are you on any medication that may affect your ability to exercise?
Do you have any allergies?
Other (Please Specify)
Please specify any other health conditions not previously mentioned.
If yes to any of the above, please describe:
Please provide any relevant information regarding your answers above.
Physical Condition
Do you have any injuries (current or historic) that may affect your ability to exercise?
Please specify the injury, location of injury on the body and what it prevents you from doing.
Goals
What are you wanting to achieve through training and/or changing your lifestyle?
What are your immediate goals (1-3 months)?
What are your short term goals (3-6 months)?
What are your long term goals (6 months to 1 year+)?
General Questions
The following questions are to gain a better understanding on what you are trying to achieve
What type of exercise do you like/dislike?
If anything, what has prevented you from consistent exercise in the past?
Examples: time, money, motivation, knowledge etc.
Submit
Submit
Signature (Guardian if under 18 years)
Should be Empty: