Online Program Design Intake Form
Health and Wellness Profile
How did you hear about us?
One of our Coaches
Current Member / Client / Affiliate
What is it you really want to achieve through Online Coaching? Why did you seek this service?
We’re not just talking about surface goals — like weight loss — here. We really want you to explore your deeper motivations and goals for doing this.
Why do you think you haven’t you achieved your goals already? What’s blocking you?
What’s standing in the way of you doing what you want to do? Why haven’t you been able to do it before now?
What have you already tried to do?
Have you tried anything in the past to change your habits, your health, your eating, and/or your body? If so, what?
How's that working out?
Of the stuff you have tried to change, how's it going now?
What awesome things might happen to you if you did make the progress you're looking to achieve?
How would your life be different? What will you be proud of? How would your environment, or mindset, or social life change because you’ve made progress?
What do you expect from working together with us?
What do you expect from your coach?
What do you think we expect from you?
What are you prepared to do to work towards your goals?
How READY are you to change
Making change involves adapting lifestyle, doing more of some things and doing less of others. How ready are you for this change?
Not ready at all
Somewhat ready, been thinking about it for a while but haven't acted yet
Totally ready, it's go time!
How WILLING are you to change
Are you willing to say YES to some things that you may currently say NO to? Like looking at nutrition differently, trying new things, adding exercise to your life, listening to us coaches, etc)
Not willing at all
Somewhat willing, it's worth a shot to try
Totally willing, I'll do whatever you say
How ABLE are you to change
Sometimes we really want to change, but just aren't able to. Whether it's a physical injury, a career that just doesn't allow for change, financially are unable to commit to a program, etc
Not able at all
Please check off all that's important to you
Please list all of your concerns about your health, eating habits, fitness, and/or body in "other section" if something is not listed here.
Lose Weight/Fat and/or Improve Body Composition
Maintain Current Weight and Body Composition
Gain Weight / Build Muscle / Add Size
Improve Physical Fitness
Improve Athletic Specific Performance
Improve Nutrition Habits
Increase Daily Energy Levels
Improve Mental Focus and Cognitive Abilities
Increase Sense of Fulfillment / Happiness
How many days per week can you commit to training?
Have you worked with a Trainer before?
Have you been a member of a gym before?
Are you interested in a gym membership at ALP-TI in addition to your coaching program? (if local to the Hamilton, Ontario area)
Please select the appropriate experience level you have with respect to weight training / exercise.
none at all
Describe what your current workout routine looks like on a weekly basis.
Include as much detail as you can think of.
Describe what your current supplement routine looks like on a weekly basis.
Include as much detail as you can think of.
Describe a typical day with respect to nutrition.
Discuss what you eat and drink from breakfast to bedtime, including medications. Point form is fine.
Describe a typical work day.
These include your daily actions (ie. 5am wakeup/shower, 530-630am breakfast/get ready for work, 630am-330pm at work, 330-4pm pick up kids from school, 5-6pm make dinner for family, 6-7pm eat dinner, 8-9pm go to the gym, 9-10pm watch tv/read a book, eat, etc)
Please describe any injuries you are currently dealing with or have had any major injuries previously.
Maybe you're dealing with a nagging back or knee injury, or maybe you have had some serious surgery or health complications we ought to know about. Anything additional to this questionnaire that you feel could help.
Please describe anything else you think we should know about you that could help design the appropriate program for you.
Maybe you travel a lot for your career. Or maybe you have had some serious surgery or health complications we ought to know about. Anything additional to this questionnaire that you feel could help.
Send me a copy of my responses.
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