COACHING ENROLLMENT
with Coach Kristy Jo
First Name
*
Last Name
*
Contact Number
*
-
Area Code
Phone Number
Gender
*
Male
Female
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
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United States
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Date Of Birth
*
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Year
Height
*
Goal Weight (if applicable)
Current Weight
*
Describe your goal: by the time you are finished training, how will you look? How will you feel? What health indicators will be improved?
*
What do you think is the biggest obstacle to reaching your goal?
*
Tell me a little about you and your life:
*
Optional
Hobbies and things that make you happy:
*
Optional
Injuries/Prescriptions/Limitations (please be descriptive):
*
Optional
Current Exercise & Eating Patterns. What diets/approaches have you tried in the past? Were they successful?
*
Optional
How many meals per day do you typically eat?
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How many calories per day do you typically eat?
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Do you currently have a gym pass or work out at home? Where is your pass? What workout equipment do you have at home?
*
Has a member of the medical profession diagnosed you with any of the following:
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Cardiovascular Disease
High blood pressure
High cholesterol
Diabetes--Type I
Diabetes--Type II
Other chronic disease
I have not been diagnosed with anything.
Do you feel any pain in your chest when you exercise?
*
Yes
No
Please describe the pain if you answered Yes.
Have you had any significant surgeries in the past year?
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No
Other
Check the box next to foods you WILL NOT or CANNOT eat:
*
Chicken
Turkey
Egg Whites
Tilapia
Cottage Cheese
Tuna
Protein Powder
Tofu
Brown Rice
Greek Yogurt
Oats
Yams
Lentils
Beans
Red Potatoes
Wheat Tortilla
Couscous
Turkey Breast
Ground Beef
Pork
Ground Turkey
Sirloin
Shrimp
Apples
Bananas
Blueberries
Strawberries
Quinoa
Grapefruit
Spaghetti Squash
Pumpkin
Pumpkin Seeds
Almonds
Cashews
Olive Oil
Coconut Oil
Avocado
Almond Milk
Peanut Butter
Broccoli
Asparagus
Zucchini
Cauliflower
Green Beans
Cucumber
Celery
Brussels Sprouts
Romaine
Spinach
Mushrooms
Bell Pepper
Carrots
Kale
Tomatoes
Coconut
Olives
Cheese
Chia/Flax Seeds
I'll eat everything!
Would you prefer yummy recipes that require prep, or more fast-grab quick prep items that are simple?
*
Are there any weird textures or food preferences you have?
*
Do you take any of the following supplements?
*
Multi-Vitamin
Calcium
Iron
Creatine
Glutamine
Pre-workout
BCAAs
Fat Burners (please stop immediately)
B Vitamins
Fish Oil
CLA
Vitamin D
Magnesium
Glucosamine
Thyroid Medication
Anti-Depressants
Birth Control
Other (please describe below)
Check any of the following that describe you:
Fast eater
Eat too much
Skip breakfast
Eat late at night
Travel frequently
More than 50% meals are away from home
Hate to cook
Confused about nutrition advice
Healthy foods are expensive
Poor snack choices
Family living with you don't like healthy foods
Eat because I have to
Negative relationship with food
Worry about my weight/body image constantly
Emotional eating when sad, lonely, bored, mad
Don't eat when stressed
Eat too much when stressed
Significant other's relationship revolves around food a lot
Do you currently have or use Protein Powder?
No, and I don't want to.
No, but I want to.
Yes, but I'll take what you want me to.
Yes, I use the brand(s) listed below (email photo of the nutrition label to powerfoodslifestyle@gmail.com)
What time do you wake up each day?
*
What time do you go to sleep each day?
*
What time do you workout each day?
*
Do you understand that Kristy Jo's coaching programs are NOT in person? All communication takes place via email, phone, and Google Hangout/Skype.
*
Yes, I understand and have no expectation of meeting my coach in person.
Blood Type
*
O
A
B
AB
I don't know
Please select any that apply:
*
I am extraverted and enthusiastic.
I see myself with a very critical eye.
I don't really like myself much.
I see myself as disciplined and dependable.
I am an anxious person and easily upset.
I am open to new experiences and change.
I am a creature of habit.
I am very reserved and quiet.
I am a sympathetic person and warm-hearted.
I am calm and emotionally stable.
Are you a Moderator or Abstainer?
*
Moderator--I rebel if I can't indulge a little daily.
Abstainer -- it's all-or-nothing for me!
How did you find The Power Foods Lifestyle?
*
Do you understand Kristy Jo is a certified Nutritionist (not a doctor or Registered Dietitian), though the Power Foods Lifestyle is Registered-Dietitian approved?
*
Yes, I understand and take full responsibility for communicating thoroughly with Kristy Jo at all times so she knows how my body is reacting.
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