Online Coaching Application Form

Origin Fitness Questionnaire
Part 1. Basic information
Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age*
years
Height*
cm
Weight*
KG
Contact Email*
example@example.com
Part 2. Lifestyle Information
What do you do for a living?
Whats the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work.:
Part 3. Medical and health information
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do any diseases run in your family?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
if yes please list:
Are you a current cigarette smoker?

YesNo
Part 4. Nutrition
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganKetogenicIIFYMNo special diet
Do you have any known food intolerances or foods that you prefer not to eat?
Part 5. Goals
Please rate your readiness for change.

12345678910
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your training?
Why?

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you ever used a Coach before?

YesNo
If yes how was your experience?
Leave blank if you prefer not to say
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?
Please Choose
What are your expectations of me as your Online Coach?
Please attach current Front, side and back photos

Browse Files
If possible Cancelof
Please Read The Following Terms and Conditions.
1.) CANCELLATIONS

Initial plan is non-refundable however coaching can be terminated at any time.

2.) UPDATES

Updates must be sent as scheduled with front and back photos attached and current weight unless you have made your coach aware in advance of something preventing this or in the case of an uncontrollable event taking place preventing this.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given is strictly confidential.

4.) Medical Health

I have sought and followed any necessary medical advice. I am fit and able to begin a diet and/or training program. I have no known existing medical conditions that I have not mentioned above.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Please sign*
Should be Empty:

Origin Fitness Questionnaire

Part 1. Basic information

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Nutrition

Part 5. Goals

Please Read The Following Terms and Conditions.