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Tell Me Your Goals

Assessment/Consent

Please fill out the following form.

Date of birth
Month
Day
Year
Gender
Male
Female
Which service are you interested in?
Virtual Health & Fitness Coaching (Meet 1-on-1 to create a strategy to reach your goals)
Virtual Personal Training (Meet 1-on-1 via live online session and going through workouts together)
In-Person Fitness Training (Meet 1-on-1 at your community gym for a 30 minute workout session)

Fitness Goals

What are your primary fitness goals?
On a scale of 1-10, how committed are you to achieving your fitness goals?
1-3
4-6
7-10

Current Fitness Level

How would you describe your current fitness level?
Beginner
Intermediate
Advanced
How often do you exercise currently?
None
1-2 days/week
3-4 days/week
>5 days/week
What types of exercise do you currently do if you are exercising?
How long do your workout sessions typically last?
<30 Minutes
30-60 Minutes
>60 Minutes

Lifestyle and Habits

How many hours of sleep do you get on average per night?
<3
3-5
>6
How would you rate the quality of your sleep?
Poor
Fair
Good
Excellent
How would you describe your stress levels?
Low
Moderate/Normal
High & need to manage better
How often do you eat out or order takeout?
None
1-2 days/week
3-4 days/week
>5 days/week
Do you smoke or consume alcohol? If yes, how frequently?
Yes
No

Nutrition and Diet

Describe your current eating habits
Regular Meals(2-3/day)
Irregular Meals(1 meals or less)
High In Ultra-Processed Foods
Are you following any specific diet?
Vegetarian
Ketogenic
Intermittent Fasting
None
Other

Motivation and Challenges

Preferences and Availability

What is your preferred times of day to work out?
Where will be your primary exercise location?
Home
Gym/Fitness Center
Outdoors
Other

Health History

Additional Information

Consent and Acknowledgment:

By signing this form, I acknowledge that the information provided in this health and fitness assessment is accurate and complete to the best of my knowledge. I understand that my health coach will use this information to develop a personalized fitness and nutrition plan tailored to my goals, preferences, and limitations.

I acknowledge that:

  1. Personal Responsibility: I am responsible for my own health and well-being. I agree to participate in the recommended exercise programs, nutrition plans, and health activities at my own risk. I understand that the advice and recommendations provided by my health coach are not a substitute for professional medical advice, diagnosis, or treatment.

  2. Medical Clearance: I confirm that I have consulted with my healthcare provider before engaging in any new exercise or nutrition program, especially if I have any pre-existing medical conditions, injuries, or concerns. If I experience any pain, discomfort, or adverse symptoms, I will stop immediately and seek medical attention.

  3. Confidentiality: I understand that all personal information shared in this assessment and during my coaching sessions will be kept confidential and will not be disclosed to any third parties without my explicit consent, except as required by law.

  4. Results Disclaimer: I acknowledge that individual results may vary, and that success in reaching my fitness and health goals depends on various factors, including my commitment and adherence to the program. My health coach cannot guarantee specific outcomes.

  5. Assumption of Risk: I understand that participation in physical activity carries inherent risks, including the possibility of injury or health complications. I assume full responsibility for any risks, injuries, or damages that may occur as a result of my participation in the coaching program.

  6. Consent to Participate: I voluntarily agree to participate in the health and fitness coaching program provided by Ask The Health Coach. I understand the nature of the activities and the potential risks involved.

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