CUSTOM COACHING APPLICATION

Full Name

First Name

Last Name

Email Address

Phone Number

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender

Age

Height

Weight

specify pounds or kilos

Body Fat Percentage

Do you have access to a gym? If not, what do you have access to?

Describe your exercise history as well as your current exercise routine.

Do you have any current or pre-existing injuries? Explain.

Describe your nutrition history, as well as your current nutritional habits.

Are you taking any supplements? If so, what are you taking, how much are you taking, and how often are you taking it?

Describe your sleep. How is the quality? The quantity?

Describe your stress levels.

Describe your specific goals.

Why are these goals important to you?

Why have you decided to seek out a coach? What are you expecting out of a client-to-coach relationship?

How many days per week can you workout?

What days of the week work best for you to workout?

On a scale of 1-10, how committed are you to reaching your goals?

1 = If I reach my goal in 3 months, or 5 years, it really doesn't matter. I'd rather spend my time and energy on other things in life even if it means putting my health and fitness on the backburner. 10 = I want to reach my goals as soon as I can. I will eat chicken and broccoli all day long if I have to. I will do anything it takes to reach my goals.

Are there any events in your schedule that will cause you to travel?

Are there any reasons training/nutrition may be interrupted in the near future?

What are your hobbies/interests?

Who is your favorite superhero?

How did you hear about Poehlmann Fitness?

Please provide any additional information you think we need to know.