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Pre-Consultation Questionnaire
Before our first meeting, I would like to know some preliminary information about you and your health. This information will be kept with extreme care and confidentiality. Please answer as accurately as you can so that we can move forward together in the most beneficial way possible.
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Name
*
Your answer
Email
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Sex
*
Male
Female
Other:
Are you hoping to maximize performance, or to ameliorate /reverse past or current problems? (Check all that apply)
*
Want to maximize athletic performance
Want to ameliorate or reverse the effects of past problems
Want to ameliorate or reverse current problems
Want long lasting active & healthy lifestyle
Other:
Required
Please describe the problems you would like to address.
*
Your answer
Have you worked on the issue(s) above with any medical practitioners or other professionals in the past?
*
Your answer
What is your goal/ objective?
What are you hoping for by working with me?
*
Your answer
Please describe your current activity level
*
Your answer
Do you have any other health concerns or issues that prevent you from being as active as you would like?
*
Your answer
If you are over 50, do you have medical clearance to exercise?
*
Yes
NO
Don't know what that is
Under 50
Other:
Are you interested in an online-based Nutritional Coaching program to improve your nutritional life and boost the effects of training? (Hint: your body will heal, recover or build much more effectively with the proper building blocks.)
*
Yes
No
Maybe
Other:
Are you interested in also working on improving your muscular strength and endurence using the BFR (Blood Flow Restriction) method to accelerate your results?
Yes
Yes, I'm curious. I want to hear more about it at my trial
No
Maybe. I want to hear more about it at my trial
Other:
Clear selection
Please note if you have any other concerns you might have about starting an exercise program with me.
Your answer
Who referred you? Or, how did you come across my website/business? (Google search, Instagram, FB, etc. )
*
Your answer
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