Coaching application
Tell me more about yourself. By learning more about YOU I can take better care of you and make sure coaching is a good fit for your needs.
* Required
Email address
*
Your email
Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Gender
*
Female
Male
Prefer not to say
Other:
Mobile Phone
*
Your answer
Address
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Your answer
Emergency contact name
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Your answer
Emergency contact number
Your answer
What are your goals? Check all that apply
*
Lose weight / fat
Gain weight
Maintain weight
Add muscle
Improve physical fitness
Look better
Feel better
Have more energy and vitality
Get control of eating habits
Get stronger
Physique competition / modeling
Improve athletic performance
Other:
Required
List all of your concerns about your health, eating habits, fitness and / or body.
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Your answer
Out of all the above concerns, which ones feel more important / urgent?
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Your answer
Why?
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Your answer
What do you expect from me as your coach?
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Your answer
What are you prepared to do to work towards your goals?
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Your answer
Have you tried anything in the past to change your habits, your health, your eating, and / or your body?
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Yes
No
If so, what?
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Your answer
Which of those things worked well for you?
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Your answer
Which of those things didn't work well for you?
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Your answer
How, specifically would you like your habits, your health, your eating, and / or your body to be different?
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Your answer
Have you already made changes to your habits, your health, your eating, and/ or your body recently?
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Yes
No
If so, what?
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Your answer
If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be?
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Your answer
Until now, what has blocked you or held you back from changing these things?
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Your answer
Right now how would you rank your overall eating / nutrition habits?
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Horrible
1
2
3
4
5
6
7
8
9
10
Awesome!!
Why?
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Your answer
Are you regularly active in sport or exercise?
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Yes
No
If so, how many hours per week?
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Fewer than 5 hours
5-9
10-14
15-19
20 or more
Required
What type of sports and / or exercise do you typically do?
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Your answer
How many hours a week do you do other types of physical activity? (e.g., housework, gardening, walking, construction)
Less than 5 hours
5-9
10-14
15-19
20 or more
Clear selection
What other types of movement and / or activities do you do?
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Your answer
Who lives with you? Check all that apply.
*
Spouse or partner(s)
Roommate(s)
Child(ren)
Pet(s)
Other family
Required
Do you have children? If yes, how many and what are their ages?
*
Your answer
Who does most of the grocery shopping in your household? Check all that apply.
Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Who does most of the cooking in your household? Check all that apply.
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Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Required
Who decides most of the menus/ meal types in your household? Check all that apply.
*
Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Required
Right now, how much do the people and things around you support health, fitness, and / or behavior change?
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Not at all
1
2
3
4
5
6
7
8
9
10
Completeley
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
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Yes
No
Do you have any health concerns such as illness, pain, or injuries right now?
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Yes
No
Are you taking any medications, either over-the-counter or prescription?
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Yes
No
On a scale of 1-10 where would you rank your health right now?
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Horrible
1
2
3
4
5
6
7
8
9
10
Awesome
On a scale of 1 to 10 how do you feel about your schedule, time use, and overall busy-ness?
My life is panicked and insane
1
2
3
4
5
6
7
8
9
10
My life is perfectly calm and relaxed
Clear selection
Given the demands of your life, what is your typical stress level on an average day?
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No stress
1
2
3
4
5
6
7
8
9
10
Extreme
On average, how many hours per night do you sleep?
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4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
How do you normally cope with your stress?
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Your answer
How READY are you to change your behaviors and habits?
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Not at all
1
2
3
4
5
6
7
8
9
10
Completely
How WILLING are you to change your behaviors and habits?
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Not at all
1
2
3
4
5
6
7
8
9
10
Completely
How ABLE are you to change your behaviors and habits?
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Not at all
1
2
3
4
5
6
7
8
9
10
Completely
Where did you hear about us?
*
Your answer
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