COACHING APPLICATION FORM Name * First Name Last Name Date of birth MM DD YYYY Mobile * Country (###) ### #### Best contact time Email * What services are you interested in? * 1-on-1 Personal Training 2-on-1 Personal Training Online Coaching Other Health Screen Has your doctor ever told you what you have a heart condition or have you ever suffered a stroke? * Yes No Do you ever experience unexplained pains in your chest at rest or during a physical activity/exercise? * Yes No Do you ever feel faint or dizziness during physical activity/ exercise that causes you to lose balance? * Yes No Have you ever had an asthma attack requiring immediate medical attention at any time over the last 12 months? * Yes No If you have diabetes (Type 1 or Type 2) have you had trouble controlling your blood glucose in the last 3 months? * Yes No Do you have any diagnosed muscle; bone or joint problems that you have been told could be made worse by participating in physical activity/ exercise? * Yes No Do you have any other conditions that may require special consideration for you to exercise? * Yes No If you answered 'YES' to any of the 7 questions, please provide more details below: What are you main goals? * Reduce Body Fat & Get Leaner Gain Muscle & Strength Sport Specific Training Other How much training experience do you have (uninterupted, consistent training blocks) <3 Months 3-6 Months 6-12 Months 12 Months + What types of training (Weekly frequency, session length and intensity) What has worked well for you in the past? What hasn't worked well in the past? Why do you think you have no seen the results you want? Which of the following describes what you are looking for from coaching? Sustainable Results Education Improved Confidence A Complete Change In Lifestyle Freedom Of Movement (Mobility, Alleviating Pain) Which of the following best describes your current approach to your training & nutrition? (Please be as honest as possible, this will help me find the best approach to coach you) There is always an excuse to not do it I procastinate and never commit I get fed up if I don't see immediate results I want to achieve results but not at all costs Other CONFIRMATION - I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct * Yes No How did you hear about us? Facebook Instagram Google Flyer Family/ Friend Thank you!