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The Starting Point
Please take the time to fill out this form so that your coach can tailor your coaching experience for you, in order to maximise your results.
37
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1
Name
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First Name
Last Name
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2
Date of Birth
*
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Date
Year
Month
Day
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3
Height?
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4
In general what are your goals?
*
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Fat Loss
Muscle Gain
Improve Athletic Performance
Look Better
Feel Better
Have More Energy
Improve confidence
Wellbeing
Fat Loss
Muscle Gain
Improve Athletic Performance
Look Better
Feel Better
Have More Energy
Improve confidence
Wellbeing
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5
Current Weight?
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If you don't know exactly, just roughly what you believe your weight to be
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6
Weight 6 months ago?
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If you don't know exactly, just roughly what you believe your weight to be
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7
Weight 3 years ago?
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If you don't know exactly, just roughly what you believe your weight to be
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8
How would you describe your general movement & workout habits currently?
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e.g. daily activity levels, workouts you perform etc
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9
Where would you rate your nutrition knowledge?
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This is all new to me
Extremely knowledgeable
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10
Which diets/eating styles have you tried in the past? Which worked for you Which didn’t?
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11
Right now, how would you rank your overall eating habits?
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Very un-nutritious
Extremely nutritious and healthy
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12
How Hungry Are You On Average?
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Don't ever feel hungry
Hungry all the time
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13
How Long Does It Take For You To Finish A Meal?
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5 Minutes or Less
5-10 Minutes
10-15 Minutes
15-20 Minutes
20+ Minutes
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14
How Many Meals Do You Eat Per Day? (Including snacks)
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7+
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15
How Many Meals Do You Cook Yourself Per Day? (Including snacks)
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Cook = You or someone you live with, has created the entire meal from scratch
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7+
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16
How much do the people around you support your health, fitness, or behaviour change?
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No support
Extremely Supportive
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17
How would you rate your health?
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Extremely unhealthy
Perfect health
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18
Describe your energy on average?
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Very tired all day long.
Filled with energy until I'm ready to sleep
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19
How do you feel about your schedule & time use?
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Far too busy
All the time in the world
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20
Are there any times of the year that are particularly busy for you?
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E.g. Tax season for Accountants.
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21
How would you rate your stress levels (on average)?
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Chilled
Extremely Stressed
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22
Describe your mood on average
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23
On average, how many hours do you sleep a night?
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24
Do You Have Trouble Falling Asleep at Night?
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YES
NO
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25
Do You Wake Up Throughout The Night?
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YES
NO
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26
How Much Caffeine Do You Regularly Consume?
*
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Coffee/Energy Drinks etc
0 Caffeinated drinks
1 Caffeinated drink
2 Caffeinated drinks
3 Caffeinated drinks
4+ Caffeinated drinks
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27
Do you drink alcohol?
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If yes, how much would you drink on average? And how frequently do you drink?
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28
Do you have any past/current injuries, aches or pains?
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if yes - list them below
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29
Do you have any health conditions I should be aware of?
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if yes - list them below
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30
Do you take any medications or supplements we should be aware of?
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31
Taking all of this into account, how specifically would you like your habits, your health, your body and/or your eating to be different?
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32
What changes are you ready/willing to make for your fitness/health goals?
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33
Until now, what has blocked you or held you back from changing these things?
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34
What changes are you NOT ready/willing to make towards your fitness/health goals?
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Any non-negotiables?
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35
What do you hope to gain out this program?
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36
What results would make you ecstatic in 12 weeks time?
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37
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
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I accept
NO
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