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Look, feel and perform...
Better!
Welcome
Program
Nutrition
Contact
Name
*
First Name
Last Name
Tell me a little bit about yourself
GOALS
What is your number one fitness goal?
Why is this important to you?
Do you have a time-frame in mind?
What barriers (if any) are holding you back?
Are there any secondary goals you would also like to work on?
EXERCISE
How would you rate your current fitness level?
Super Fit
Fitter Than Most
Active But Unfit
Couch Potato
Are you currently exercising regularly?
Yes
No
If 'Yes' please provide details?
Where will you be exercising? (Home, outdoors, other)
What exercise equipment (if any) do you have access to?
What types of exercise or physical activities do you enjoy?
Not including structured exercise, how active are you on a daily basis?
Very active
Active
Moderate
Inactive
Very inactive
Realistically, how much time do you have per week to exercise?
PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you perform physical activity?
Yes
No
In the past month, have you had chest pain when you were not performing any physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Yes
No
Do you know of any other reason why you should not engage in physical activity?
Yes
No
If you have answered 'Yes' to any of the above please provide more details
Is there anything else I should be aware of regarding your ability to exercise safely?
NUTRITION
Briefly describe a typical days eating? Meals, timings, snacks, drinks etc.
Does this pattern change much at the weekend?
If you could improve one thing about the way you eat or drink, what would it be?
MISCELLANEOUS
How old are you?
<21
21-30
31-40
41-50
51-60
61-70
70+
How would you rate your current stress levels?
Very High
High
Moderate
Low
Very Low
On average how would you rate your sleep?
Good
Mixed
Bad
How would you like to measure progress? Tick all that apply
Body Measurements
Fitness Performance
Subjective Measure (e.g. energy levels)
Other Measurement
LAST BUT NOT LEAST
What are you looking for from a coach? How can I best help you?
