Questionnaire
Personal Info
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Occupation
*
Starting Bodyweight
*
Goals
What are your primary health & fitness goals?
*
What is your main motivation(s) to acheive these goals?
*
Do you have any specific events or milestones? (Competition / holiday / wedding etc.)
*
Exercise & Activity
What type of excercise do you currently do? (E.g. strength training, cardio, sports, other)
*
How often, and for how long do you train each week?
*
Do you have any current training goals or performance targets?
*
Current Nutrition & Eating Habits
Can you describe your typical daily eating pattern? (It's important you are absoltuely honest & detailed as possible here, we're heading to making a change, but I need to ensure I'm working around your actual lifestyle / habits where possible)
*
Do you currently track your nutrition? Select which you do
*
Calories
Macronutrients
Protein
Micronutrients
None
How would you rate your current energy levels throughout the day? (low, moderate, high? Do you burn out later in the day? Wake up groggy but improve as the day goes on?)
*
Dietary Preferences & Restrictions
Do you follow any specific dietary protocols? (e.g. vegan, vegetarian)
*
Do you have any food allergies or intolerances?
*
Any particular foods you can not tolerate eating preference wise? Please be thorough!
*
Hydration & Electrolytes
How much water do you typically drink daily?
*
Do you take any electrolyte / hydration supplements?
*
Sleep & Recovery
Describe your typical sleep pattern (hours / night, bed time, wake time)
*
Do you tend to feel well rested when you wake in the morning?
*
How would you rate your recovery rate from workouts? (1-10)
*
Lifestyle & Stress
What does a typical day in your life look like? (Work, family, social commitments etc)
*
Do you experience high levels of stress day to day?
*
Supplement Use
Are you currently using any supplements? If so, detail them (e.g. protein powder, vitamins, minerals etc.)
*
Do you now, or have you ever used PEDs? If so please describe current cycle and history of use.
*
Medical History & Injuries
Do you have any pre-existing medical conditions that might affect your nutrition and / or fitness, or ability to follow a fitness and/or diet programme?
*
Do you have any injuries that affect training in any way?
*
Have you had any recent surgeries?
*
Photos
Please upload 3 images of you; Front, side & rear relaxed showing upper & lower body. This is so I have a firm understanding of body composition.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Terms of Service - PLEASE READ CAREFULLY
None Refundable
Refunds are generally not provided, however exceptional cases at the sole descretion of Sam may be considered. Requests must be made directly to Sam for review.
Full Liability Waiver
You agree to release any liability from Sam for any loss, damage or injury that may occur whilst receiving the services. You understand that participating in any activity or service provided by Sam involved some risks and accept full responsibility for your safety and well-being.
Information Sharing Restricted
You agree not to share, distribute, or disclose any confidential information obtained through interactions with Sam, except as mututally agreed in writing. Unauthorised sharing of such information will be directly addressed by Sam.
Disclaimer
Sam Hinks is not a licensed medical professional or dietician or physiotherapist. The information provided in any of his communication should not be construed as medical or nutritional advice and should not be used for the diagnosis, treatment, cure, or prevention of any health condition or injury. It is not a substitute for professional medical guidance from a qualified healthcare provider or nutrition advice from a qualified dietician. Please consult with your physician or a qualified healthcare professional regarding any health concerns and a qualified dietician for safe and appropriate diet advice. Any injuries a licensed physiotherapist should be consulted with. The content of all coaching communications with Sam on any platform is confidential and any advice shared is hypothetical. In particular Sam Hinks and anyone associated with his coaching company does not encourage or condone the use of illegal performance enhancing substances and any advice shared is from a hypothetical standpoint. The use of these substances including but not limited to anabolic steroids, peptides, nootropics, metabolic modulators, diuretics, amphetamines including, legal, illegal substances and misuse of prescription medications can lead to serious life altering illness, injury and death. As such the use of any or similar substances is a personal choice and neither Sam Hinks nor his coaching company will be liable for and consequences of taking these or similar substances. This plan is designed to support your health, performance and body composition goals It is not intendedd to replace medical advice or override any recommendations made by your healthcare provider. If you're managing a currect health condition, you must make Sam Hinks aware of this and continue to monitor your condition as before. For example, if you're diabetic (type 1 or insulin dependant type 2), you must continue to monitor your blood glucose levels as advised by your healtcare provider. Adjust insulin doses according to your personal carb rations, correction factors and individual needs. Seek advise from your diabetes care teams before makign any significant changes to your nutrition, supplementation or training. Whilst I will work with you in your condition, and take guidance from you & your health team on your personal symptoms etc. You understand this plan is not intended to diagnose, treat or cure any medical condition. You acknowledge that the management of your condition remains your responsibility and you should always refer back to your medical team.
Cancellation Notice
Please be advised that we reserve the right to terminate our services immediately if your conduct is found to be inconsistent with our values, with no refund provided for any unused days.
Please sign to show you understand & accept the above terms
My Products
*
prev
next
( X )
SJH Blueprint
£75.00
£
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Submit
Submit
Should be Empty: