Coaching Client FormYour information is confidential and is only used by your coach to optimise your training and nutrition experience. Name * First Name Last Name Email * Phone (###) ### #### What is your current weight? * In kilograms. If you don't currently own scales please get yourself some ASAP! What is your age? * What is your height? * In cm. What is you occupation? * Excluding exercise, how physically active are you in your day to day life? * Inactive Moderatley active Very active Would you consider yourself to be a morning lark or night owl? * Morning lark Night owl What is your average daily step count? * Below 5,000 steps Between 6,000 - 8,000 steps Between 8,000 - 10,000 steps Between 10,000 - 12,000 steps On average how many hours of sleep per night are you currently getting? * 5 - 6 hours 6 - 7 hours 7 - 8 hours 8 - 9 hours 9 plus hours Are you currently tracking your nutrition? If so please provide details of your macro totals for a typical day. * Have you been told by your doctor that you have high blood pressure? * Yes No Have you been told by your doctor that you have high cholesterol? * Yes No Have you been told by your doctor that you have high blood sugar? * Yes No Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months? * Yes No If yes, please give details Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? * Yes No Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? * Yes No Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? * Yes No Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? * Yes No If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? * Yes No Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? * Yes No Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? * Yes No Are you a male over the age of 45 years or a female over the age of 55 years? * Yes No Has anyone in your family under the age of 55 years suffered from heart disease or stroke? * Yes No Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months? * Yes No Are you currently taking a prescribed medication(s) for any medical conditions(s)? * Yes No If you answered yes, please give details Are you pregnant or have you given birth within the last 12 months? * Yes No Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity? * Yes No What specifically do you want to achieve by working with us (please list your goals in order of priority)? * What time frame do you want to achieve these goals in? * On a scale of 1-5 how important is it for you to achieve your primary goal? * 1 being not overly important and 5 being very important to you 1 2 3 4 5 Why is this important to you? What would happen if you achieved it? What would happen if you didn't? * What have you tried in the past to solve this? * Eg: past diets, past exercise regimes etc If not, what has kept you from starting sooner? * What is your morning resting heart rate (beats per minute)? * Below 50 Between 50 - 60 Between 60 - 70 Between 70 - 80 Over 80 On a scale of 1-5 how would you rate your daily stress level? * 1 being not of high stress and 5 being highly stressful 1 2 3 4 5 On a scale of 1-5 how would you rate your sleep quality? * 1 2 3 4 5 What time do you normally get to bed by? * Before 9pm Between 9pm - 10pm Between 10pm - 11pm Between 11pm - 12am After 12am On a scale of 1-5 how would you rate your energy levels through out the day? * 1 being low energy and 5 being high energy 1 2 3 4 5 On a scale of 1-5 how would you rate your libido? This question is optional Prefer not to say 1 2 3 4 5 On a scale of 1-5 how would you rate your digestion? * 1 being slow digestion and 5 being fast 1 2 3 4 5 Do you ever or have you suffered from any of the following? Depression Anxiety Nervousness Agression None Are you currently taking any supplements? If so please list them here. * Are you aware of any food allergies, restrictions or sensitivities that you may have? (E.g. gluten, wheat, nuts or lactose) * Do you have any food cravings? * What is you exercise history? * Are you currently following a structured exercise program? What time of the day do you normally train at? Is this time flexible or not? * Please list what foods you would consume in a typical day. Be as specific as possible in terms of food quantities and meal times. * Please answer for 3 week days & nights and 1 weekend day & night Tuesday * Friday * Saturday * Are there certain times of the day when you are not able to eat? * How many glasses of water do you typically drink in a day? * Please list any other non alcoholic beverages you consume during the day such as coffee, tea, or soft drinks. Specify exact amounts where possible. * Be as specific as possible. If you have coffee, list what type. Have you ever felt nervousness, jittery or experienced anxiety after drinking caffeine? Have you ever tried decaf? * Do you drink alcohol? If so, how many alcoholic beverages do you consume throughout the week? * On a scale of 1-5 how willing are you to significantly modify your diet? 1 2 3 3 5 Are you willing to take several nutritional supplements each day? * Yes No are you willing to track everything you eat each day? * Yes No Are you willing to modify your lifestyle (e.g. work demands, sleep habits) ? * Yes No Are you willing to practice daily relaxation techniques? Yes No Are you willing to engage in regular exercise? * Yes No On a scale of 1-5 how confident are you of your ability to organize and follow through on the above health related activities? * 1 2 3 4 5 On a scale of 1-5 how supportive do you think the people in your household will be to your implementing the above changes? * 1 2 3 4 5 On a scale of 1-5 how much ongoing support and contact (e.g. telephone consults, e-mail correspondence) from your professional staff would be helpful to you as you implement your personal health program? * 1 2 3 4 5 Thank you! I can’t wait to start working with you
