In Person Coaching Pre Exercise Questionnaire
Please answer the below questions and your preferred day/ time for a booking below. Please be honest, it helps me to help you, this is a judgement free zone!
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Full Name  *
Date of birth  *
MM
/
DD
/
YYYY
Phone Number  *
Email Address *
Occupation (yes, a SAHM is an occupation Mumma) *
Preferred day and time for a consult? *
What package are you interested in? *
Required
Do you have a preferred trainer?  *
Required
Instagram Handle 
What is your exercise experience? Have you ever been in a gym? Do you have any experience with a barbell or DB's?   *
What is your current fitness routine? *
How many days per week do you train regularly?  *
None
7 days per week
What do you enjoy for exercise? *
What do you not enjoy for exercise? *
Do you have gym access? If yes, where?  *
What currently stops you from exercising? What has stopped you in the past?
 *
Do you have family/ social support? Please let me know who is at home with you
 *
How many alcoholic drinks would you have (on average) per week?
 *
None
10 +
How many serves of fruit do you have per day?
 *
None
5+
How many serves of vegetables do you have per day?
 *
None
5+
What do you struggle most with in your nutritional intake? Why? 
 *
What support do you need with your nutrition?
 *
Goals 
Please describe two or your main goals, try and make only one a physical appearance goal and the other either nutrition, strength or consistency based. Please be specific e.g. I want to lose 5kg or I want to do 10 push ups on my toes
Goal 1
 *
Goals 2
 *
Medical / Health Questionnaire 
Please answer the below questions, let me know in the comments if you, your brother, sister, Mum or Dad have had any of the following conditions
Heart Condition
 *
Chest Pain 
 *
Low or High Blood pressure 
 *
Dizziness during or after exercise 
 *
Pre/ Post Natal
 *
If yes, how long ago? Did you have any pregnancy or birth complications (tears, prolapse, birth trauma, emergency C-section etc)?
How many children do you have - tell me about them! 
Are you on any medications?
 *
If yes, what are they? 
Do you have any joint or bone issues?
 *
Do you have any injuries?
 *
Do you have any mental health history I should be aware of?
 *
Diabetes? *
Asthma? *
Do you know any other information that may impact your ability to exercise? *
If you answered yes to any of the above please explain in detail here 
Do you smoke or vape? *
What contraception are you on?
Do you currently track your cycle? If yes, what day are you? 
Social Media 

We use photos or videos from client sessions on Social Media or for advertising with your permission

Do you give Reliberate Fitness permission to be able to use your image/ videos for promotional or social media purposes?
 *
Privacy Policy 
We respect your privacy - please see full privacy policy here https://www.reliberatefitness.co.nz/
Acknowledgment and Liability Waiver:


I understand that this personal training program may include exercises designed to improve the musculoskeletal system, which involves enhancing muscular endurance, strength, and overall flexibility, as well as improving body composition by increasing muscle and reducing body fat.

I acknowledge that Reliberate Fitness is not liable for any damages or personal injuries sustained during or resulting from participation in the personal training program or sessions.

Any questions I had have been answered to my satisfaction, and I understand that further inquiries can be directed to contact@reliberatefitness.co.nz

I recognise that the instructor is not qualified to provide medical advice regarding my fitness, and that any fitness-related information provided serves as a guideline based on my abilities.

I have provided accurate responses to all questions asked to the best of my ability and understand the guidance provided.

By participating, I agree to follow all safety instructions during training sessions.

I understand that the trainer is not responsible for any injuries that may occur, and I will take the necessary precautions to avoid injury.

Do you agree to the above payment policy and liability waiver? *
Required
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