Name

Email

Location

Phone

Date of Birth

Occupation

Have you ever been told you have a heart condition or have you ever suffered a stroke?
YesNo
Do you experience unexplained pains or discomfort in your chest when exercising?
YesNo
Do you feel faint/dizzy during exercise?
YesNo
Do you have any other medical conditions that require special consideration before you exercise?
YesNo

What is your main reason for requiring coaching?

Current pain or injuries

Previous pain or injuries

Training History

Have you ever had a coach before?
YesNo

Describe your current training

What are you short term goals?

What are you long term goals?

Are there any specific areas you feel you need to improve more on?
Endurance/distanceSpeedPowerFitnessWeight loss

How many times per week can you do a 10-15 minute mobility routine?
—Please choose an option—Once per week2-3 time per week4-5 times per week6-7 times per week
How many times per week could you do a 30-60 minute session to improve strength and conditioning?
—Please choose an option—Once per week2-3 time per week4-5 times per week

Do you foresee any obstacles to you achieving your goal?