Andrea Du Cane (Kettlebell Fitness, LLC) Personal Coaching Client Questionnaire
Please fill out all of the questions below as thoroughly as possible.
Email address *
First Name *
Your answer
Last Name *
Your answer
Skype ID (if you have one) *
Your answer
Phone Number *
Your answer
Address, City, State, Country *
Your answer
Gender *
Age *
Your answer
Height (feet and inches) *
Your answer
Weight (pounds) *
Your answer
Bodyfat percentage (if known, not required)
Your answer
How did you find about the Kettlebell Fitness Coaching Program and what interested you in it? *
Your answer
Can you describe your short-term (within the next 3 months) and long-term goals (within the next year)? *
Your answer
Please list any and ALL health problems or conditions including accidents, injuries (past or present), or any other issues you’ve experienced? *
Your answer
Please list any and ALL medications you are currently taking: *
Your answer
Do you have any specific nutritional restrictions or food allergies? *
Your answer
Describe your current eating habits/diet, i.e. what is your typical breakfast, lunch, dinner, snacks and beverages throughout the week? *
Do you eat out a lot? Do you make food at home? What restaurants or fast food are your go-tos?
Your answer
Are you currently training? If so, please tell us specifically what you are currently doing. *
Your answer
Are you experienced with kettlebell training? *
What's your athletic background? *
Your answer
What types of physical activity do you ENJOY doing and what types do you dislike doing? *
Your answer
Do you have access to a gym or equipment at home? If yes, what equipment do you have access to? *
ie. dumbbell/kettlebell quantity & sizes, jump rope, yoga mat, pullup bar, full barbell setup, etc.
Your answer
Check which best describes your current fitness level: *
Anything else you'd like to share?
Your answer
By checking "YES" below, you acknowledge that you are physically sound to proceed with the participation of this program. You, the undersigned further stipulate that you are fully insured by an Accidental and/or Medical Insurance Policy that will cover any personal injury or illness that may occur as a result of activities related to participation in this coaching program. Andrea Du Cane shall not be held responsible for accidents, injuries, illness, or loss of personal property, suffered by the undersigned while participating in this coaching program. *
Required
Please type your full name below as your legal signature: *
Your answer
Date of signature: *
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