Name
*
First Name
Last Name
Phone Number
*
Email
*
Weight (kg)
*
Hight (cm)
*
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Emergency Contact Name and Mobile Phone
What Results Are You Looking For, choose all that apply.
Other:
Please list all your current concerns about your health, fitness, eating habits, injuries, and/ or body
Out of all of the above mentioned concerns, witch 3 feel most important / urgent?
Why are these 3 the most important/urgent too you?
Are you regularly active in sports and/or exercise?
Yes
No
if yes, How many hours pr week?
What type of training do you enjoy the most? (past and present)
How many hours a week do you typically do other physical activities, like house work, gardening, walking, stand up/move around at work/home, home repairs ect?
At what times during the day would you prefer to exercise/train?
How often are you willing to train a week to reach your goal?
How many times pr week can you realistically workout the way your schedule is now?
Where do you train, what equipment do you have available for training? (For home, include if you have stairs, garden to run in, running outside, bike ect)
Have you previously tried to change your habits regarding health, eating, sleep, stress management and / or your body? If yes what have you tried?
In the past what has worked well for you?
How would you specifically like for your habits, your health, your eating and / or your body to be different?
If you were considering to change anything, what would you like to change in the future about your habits, your health, your eating, and/or your body?
Until now what has held you back from making these changes?
How would you rate your overall eating/nutrition habits?
Rate your habit on a 0-10 scale where 0 is HORRIBLE and 10 is AWESOME
How would you rate your overall training/exercise habits?
Rate it on a 0-10 scale where 0 is HORRIBLE and 10 is AWESOME
Describe your household, who do you live with, partners, children, parents, pets?
Who does the grocery shopping in your household?
Who does the cooking in your household?
Who decides the menu, meal types in your household?
Right now, how much do the people and things around you support health, fitness, and / or behavior change?
Rate it on a 0-10 scale where 0 is Not At All and 10 is Completely Behind Me
Describe your ideal day, from the when you wake up until you go to bed. Include both weekday & weekend.
What is your current health like?
Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
Yes
No
If yes, what?
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
Yes
No
If Yes, elaborate:
Right now, are you taking any medications, either over-the-counter or prescription?
Yes
No
How would you rank your health right now?
Rate it on a 0-10 scale where 0 is HORRIBLE and 10 is AWESOME
Why do you rank your health there?
On the scale of 1-10 how do you feel about your schedule, time use and overall busy-ness?
Rate your habit on a 0-10 scale where 0 is Hectic And Stressed and 10 is Relaxed And Perfect Balance
How is your stress and recovery?
Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can:
Given all the demands of your life, what is your typical stress level on an average day?
Rate it on a 0-10 scale where 0 is No Stress and 10 is Extremely Stressed
On Average how many hours of sleep do you get pr night?
Less Than 4
5
6
7
8
9
10
10+
How do you normally cope with your stress?
what activities and/or strategies do you use to calm you down/relax
How READY are you to change your behaviors and habits?
Rate it on a 0-10 scale where 0 is Not At All and 10 is Bring It On
How WILLING are you to change your behaviors and habits?
Rate it on a 0-10 scale where 0 is Not At All and 10 is Bring It On
How ABLE are you to change your behaviors and habits?
Rate it on a 0-10 scale where 0 is Not At All and 10 is Bring It On
What do you expect from me as your coach?
How can I help you? I have some ideas but would like to know what kind of support have you found helpful in the past, how much support do you think you need to be successful?
What are you prepared to change to achieve your goals?
What are you NOT prepared to change to achieve your goals?
Anything else I should know about or you want to include?
