Health Blueprint

Health Blueprint
Personal Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Phone Number*
Email*
example@example.com
Instagram/Social Media Handle*
Address*

House Name/Number

Street Name

TownCounty/City

Post Code
Height & Weight*
A few things before you get started with the Questions

This is a very comprehensive questionnaire, it will take 15 - 20 minutes to complete fully so please set some time aside before starting.

Please try to answer all questions as best you can. The more information you can supply the better we can understand your individual situation and structure recommendations more effectively.

Please dont worry if you cannot think of a specific answer to any of the questions, there is no right or wrong answer, Just put whatever comes to mind, any information can help even if you think it may not be relvent to the question.

Please take your time to fill in this form, you are welcome to contact me if you have any quieries regarding some of the questions and I will be happy to advise.

If you are really unsure please type "I am unsure about this question" and we can discuss it further on our next call.

Exercise/Movement

The following questions are aimed at understanding your current activity level.
Briefly describe how often you deliberately exercise per week and what types of activities you do. Also include what time you usually workout.*
This is anything you purposely do as exercise such as Gym, Swimming, Cycling, Running, Long Walks etc.
Briefly describe how much Non-Exercise activity you get per day. (walking, active working, gardening, cleaning, house chores etc).*
This is the walking you do throughout your day, moving around work or home, chores like cleaning the house etc, manual/physical tasks like lifting or moving things or short dog walks etc.
What types of Exercise/Activity do you Enjoy and/or Dislike the most? (and why?)*
Do you Recover well from exercise? (Muscles aches, DOMS etc)*

My muscles ache for 3+ days after exercise.My muscles ache for 2 days after exercise.My muscles don't ache at all in the days after exercise.

Goals/Coaching

The following questions are aimed at understanding your goals and what you are looking to gain from this coaching relationship and beyond
Please explain your current health goals, then rate how important each goal is on a scale of 1 - 10, 10 being most important.*
What are you looking to work on and improve within the next 6 to 12 months?
Please explain your long-term health goals, then rate how important each goal is on a scale of 1 - 10, 10 being most important.*
What would you like your Health/Lifestyle to look like in 5 or 10 years?
What are your main reasons/motivations for wanting to improve your health and lifestyle? and why have you decided to take action now?*
If money and time were unlimited, what would you look for, or expect from a coaching program?*
Do you feel that there is anything within your home or work life that may be restricting your ability to succeed in improving your Health/Lifestyle?*
Please feel free to share anything else you feel may help us during your consultation
Should be Empty: