Adult Wellness Coaching

I appreciate your expressed interest in doing a Private Coaching program with us. Whether it is the Enhanced or Platinum Coaching model, you are in good hands.

In order for me to provide you with the best possible program to reach your goals, I need you to fill out this questionnaire to the best of your ability. Every question has a purpose, so please don’t skip any. This might be rather lengthy, so take your time, and press the submit button when you are done.

If you do not have the stats for a question, just put “do not know.” If a question does not apply to you, just put “not applicable.” Remember, the more information you can give me, the better your coach can put together a program perfect for you!

Once we receive your submission, your coach or someone from our staff will reach out to you within 24 hours on how we will be proceeding.

Let’s get it on!! ☺

Email
This field is for validation purposes and should be left unchanged.
Introductory Stats
Name*
First Last
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Cell)*
For our weekly checkins, we prefer video communication like Zoom, but this would be the next best case.
Can we text you?*
- Yes
- No
Date of Birth*
Sex
- Male
- Female
Height
Weight
Body Fat Percentage (If Known)
Shoulders Measurement
Chest Measurement
Waist Measurement
Hips Measurement
Arms Measurement
Upper Thighs Measurement
Calf Measurement
Blood Pressure
If you can recall from your last doctor's visit.
How long can you hold a plank?
How far down can you touch your toes while keeping your legs straight?*
How well can you do an overhead squat holding a broomstick?*
Any other measurables you want to add. Number of pushups, dress size, whatever
Athletic Background
If you played varsity sports in high school, please list them
Please list the recognition you received for each varsity sport if any (i.e. captain, all league, team MVP)
If you played sports in college, please tell your college and the sport(s) you played
Please list the recognition you received for your collegiate sport if any (i.e. captain, all league, team MVP)
If you played sports beyond college in the professional ranks, national teams, semi-pro, overseas, etc., please list your teams and sports
Please list the recognition you received for your professional sport if any (i.e. captain, all league, team MVP)
Exercise Program
How often have you used dumbbells with your workouts?*
How often do you use free weights with a bar in your workout program?*
Do you know how to do the Olympic lifts (at least a clean, snatch, and variations)?*
If you are currently working out, please list the exercises you are doing (don't list cardio, that is later)*
Any classes you are taking, list them and give a brief explanation what the class entails. Any and every class you are currently taking please. If not working out, just say so.
Please tell me any follow up details you need to with this workout (training split, frequency, intensity, sets/reps, etc.)*
How often you are working out each week, intensity, anything else please.
If you are doing cardio with your workout, please explain what you are doing for cardio*
If you are not doing any cardio, please state that.
If you are not working out, please tell me how long it has been since you have been on a consistent workout routine
If you haven't been working out, what have been the biggest obstacles keeping you from that and why will it be different this time?
Goals
What are your immediate short term goals that you want to accomplish in life (next 3 months)? - Just in general, not specific to my service.*
What would be your long term goals that you want to accomplish (a year out)? - Just in general not specific to my service.*
What are the health related goals we need to consider that you didn't previously mention (build muscle/size, lose weight/fat)?*
How will accomplishing your health goals help you with your first two goals you discussed?*
Have you tried to accomplish your goals before and not succeeded? If so, why?
What would be your biggest obstacle to overcome to accomplish your goals?
Besides me dropping the ball and giving you a crappy program (which won't happen), are there any other excuses you can think of that would keep you from success for this program? I want to eliminate all excuses.*
How will my online coaching help you accomplish your goals?
Have you ever used an online service like this before? If yes, please list what it was, success that you did or did not accomplish, and why you aren't using them again?
Have you ever hired a personal trainer or athletic training company to train you offline and get you to accomplish your goals? If yes, critique how beneficial it was or wasn't.
Why are you choosing this particular time to try my service and get you to where you want to be?*
Why did you ultimately decide that this program was the best option to help you accomplish your goals?*
How did you hear about us (be specific)?*
If referred: please tell us by whom, so we can thank them. Or list the website, fitness pro, etc.
Medical Issues
Please list any illnesses, aches, pains, medical conditions, that could manifest during your training. Please describe in detail*
Are you on any medications? If so, please list*
If not, put None.
Do you have any allergies or medications? If so, please list*
If you have no allergies, put None.
Once more, any aches, strains, anything we need to know that is bothering you currently?*
These are the "I didn't think it was that big a deal" or "this is something I live with nothing to worry about" type issues.
Any other medical issues you need to tell us*
Last chance to make sure we know everything.
Nutrition
On a scale of 1 (poor) to 5 (great), how do you rate your eating habits?
Please choose your feeling on your eating habit
I get at least 5 servings (combine) of fruits and vegetables
I take a quality multi-vitamin daily
I struggle with food cravings in the middle of the day
What is the one food you eat all the time, know is not good for you, but you can't control yourself? Why?
Besides a multivitamin, have you ever taken any supplements? If yes, list them and explain why. If no, explain why not.
Have you ever taken a fad diet (Zone, South Beach, etc.)? If so, which one and what happened?
How do you view eating? Are you emotionally driven? Does it mean anything to you? Etc.
Your current eating plan? Is it a plan at all? How do you decide what you are eating on a daily basis?
Please list down, in an orderly fashion, what you have eaten and drank in the last 2 or 3 days.
Exercise Equipment
Do you have access to dumbbells and benches or stability balls?
Do you have access to bumper plates and/or a lifting platform?
Do you have access to free weights and bars or Olympic bars?
Do you have access to kettlebells?
Do you have access to hammer strength equipment?
Do you have access to any other exercise machines such as cybex, nautilus, etc.?
Do you have access to medicine balls? If so, please specify the weights:
Do you have access to stability balls?
Do you have access to a TRX suspension unit?
Do you have a location to run sprints up to 40 yards?
Do you have a space 40'x40' to do agility, plyometric work?
In the program, I have some drills where you can use extra equipment. If you don't already have access to it. What would be your budget to purchase extra equipment to improve your speed/power?
Some drills utilize a partner. Do you have someone who could help you out?
Personality (Who You Are and What Makes You Tick)
If you played organized sports before, did you ever quit in the middle of the season? Why?
What do you like to do for fun?
Favorite Music?
Do you have any close family or friends that knows what you are going to be doing? Who are they? What type of support will you expect from them?*
What are your favorite hobbies?
Do you have any pets?
Have you ever committed to a project and not see it through to the end? If yes, why?*
Why would I want to work with you?*
Favorite books or magazines
Favorite sport and team(s)
Favorite athlete and why?
Favorite TV Shows
Favorite Movies
What do I need to know about you to make this coaching as successful as possible? What do I or my coaching staff need to do?*
Anything else I need to know about you
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- Exercise AND Nutrition will directly affect any goals to be achieved from this program (both good and bad). I FULLY understand that I should not expect noticeable results if I am less than 90% compliant to BOTH my exercise program AND my nutrition program.
- When I see the results I'm looking for, I will definitely provide an awesome testimonial and a picture to use at your discretion.
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- I will have a positive attitude and have fun. I will not use words such as "No" or "Can't", but instead use words such as "I will try my best." I will allow the specialists to encourage and push me to a fitness level that I never imagined.
By submitting this form, everything that you have written is true and you indicate that you agree to the Terms of Use Agreement and have read and understand the Privacy Policy and Medical Disclaimer of the Fitness Planning Consultants, Inc. Fitness Planning Consultants, Inc. shall not be liable to the signee, nor any other person, for any claims or cause of action whatsoever arising out of or connected with the services of Fitness Planning Consultants, Inc.; and that I hereby release and discharge Fitness Planning Consultants, Inc. from any such claims or actions.