Powell Performance - Intake Questionnaire
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Email *
Name *
Address *
Phone number
Preferred Time to meet with the coaching staff? *
Age in years
What is your height in inches?
What is your weight in pounds
What is your biological gender?
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What is your most important goal?
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Are you an athlete?
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If you are an athlete, please put your sport and position below:
What does success look like to you?
How will you know when you have reached your goals?
What about your life will be better once you've reached them?
Do you have a tape measure?
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Are you willing and able to take measurements to track your progress and results?
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Are you willing and able to take progress pictures?
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Which of the following best describes your current exercise regiment?
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Do you have any current injuries limiting your ability to exercise or perform?
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If yes, please tell us what it is
What is your biggest limiting factor in your diet?
Which of the following protein sources do you enjoy?
Which of the following carbohydrate sources do you enjoy?
Which of the following fruit carbohydrate sources do you enjoy?
Which of the following vegetables do you enjoy?
Which of the following healthy fats do you enjoy?
Do you take any supplements? If yes, please mark below:
How much caffeine do you take in daily? Yes your pre-workout amount should be included here
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What did you eat yesterday? *
Can you recall the last 3 days of food intake? If not please answer what a normal breakfast, lunch and dinner look like for you *
Are there any foods that you're sensitive to (e.g., they cause excessive gas, bloating, other GI upset, stuffiness, headaches, rashes, acne, etc.)? If yes, please answer which one on the following page
Which foods are you intolerant to
Any food allergies?
What does your training look like now?
Any SPECIFIC training goals?
How many days a week do you want to train?
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Do you know your Clean max? If so, please list it below, if not leave blank:
Do you know your Snatch max? If so, please list it below, if not leave blank:
Do you know your Squat max? If so, please list it below, if not leave blank please
Do you know your Deadlift max? If so, please list it below, if not leave blank please
Do you know your Bench Press max? If so, please list it below, if not leave blank please
Do you know your Military Press max? If so, please list it below, if not leave blank please
Please check all boxes for equipment you have available to you MOST of the time:
Strongman competitors ONLY, what event equipment do you have access to consistently?
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Taking any prescription medications? If yes, please list
Any other treatments or medical attention you are on or conducting?
How often do you drink alcohol?
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How often do you smoke cigarettes?
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How often do you take over the counter (OTC) medication?
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Scale of 1-10, with 10 being the highest, how would you rate your stress level at home?
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Do you work? If yes, on average days, what stress level do you have there?
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On the same 1-10 scale, how well do you cope with stress?
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Does your stress level affect your eating AND / OR training?
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What are your 3 biggest goals to get out of this coaching?
Which of the following coaching lessons are you most excited about or feel you need the most?
Would you be interested in purchasing an E-Cookbook to help you with your goals?
Anything else you think we should know about you or your eating and fitness journey? *
Powell Performance has the right to store and process any information I provide and to share the information with my coach *
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I consent to a medical release for my coach and Registered Dietitian to see any medical information I have answered in this questionnaire *
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A copy of your responses will be emailed to the address you provided.
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