Custom Program Design Questionnaire

custom design

New Client Custom Design Intake Form

Full Name *

First

Last

Email Address *

Phone Number *

Date of Birth *

Current Body Weight *

Goal Body Weight *

What is your current occupation? *

What is your current work schedule? *

(Days, hours, other)

What is your current family situation? *

(Single, Married, Kids, Student, animals, other)

Are you currently following a nutrition program? *

Are you currently following a workout program? *

Why do you want to hire a personal coach? *

How long have you been working out? *

What type of training are you interested in? *

(Bodybuilding, Olympic weightlifting, Powerlifting, etc)

What type(s) of training have worked well for you in the past? *

What type(s) of training have not worked well for you in the past? *

What are your short-term goals? And why? *

What are your long-term goals? And why? *

Have you worked with a personal coach before? *

On average how many hours do you sleep? *

Rate your sleep quality on a scale of 1-5. *

1 = very bad | 5 = very good

What time do you usually fall asleep? *

How often do you wake up during the night? *

Briefly describe your daily energy levels. *

Rate your stress level on a scale of 1-5. *

1 = no stress | 5 = very stressed

Describe what success looks like at the end of this coaching program? *

Do you have any known allergies to medications, food, or the environment? *

Are you taking any over the counter nutritional supplements? *

(Protein powder, vitamins, minerals, probiotics, etc)

Are you taking any prescribed medications? *

Do you have any pre-existing injuries or limitations? *

Would you like to provide any additional information? *