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ELITE 1-ON-1 COACHING

30-Point Health Assessment

& Questionnaire

1. Name*

2. Address*

3. Phone*

4. Email*

5. Birthday*

Day

Month

Year

6. Has your doctor ever told you that you have a heart condition and that you should only do physical activity recommended by a doctor ? *

YES

NO

7. Do you feel pain in your chest when you do physical activity? *

YES

NO

8. Have you ever experienced a rapid heartbeat or palpitations? *

YES

NO

9. Do you lose your balance because of dizziness or do you ever lose consciousness?*

YES

NO

10. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *

YES

NO

11. Please list any injuries past or present that I should be made aware of & any information around them that will assist with your exercise prescription*

12. Are you aware of any reason you should not engage in physical activity? (N/A if not applicable)*

13. Currently on medication for blood pressure or heart condition? *

YES

NO

14. On a scale of 1 (worst ever) to 10 (best ever), how would you rate your current level of fitness?*

1

2

3

4

5

6

7

8

9

10

15. On a scale of 1 (poor) to 10 (excellent) how would you rate your current eating habits?*

1

2

3

4

5

6

7

8

9

10

16. On a scale of 1 (low) to 10 (high) how would you rate your stress levels?*

1

2

3

4

5

6

7

8

9

10

17. How many times per week do you typically take part in physical activities?*

18. How many cigarettes do you smoke daily?*

19. How many units of alcohol do you typically consume per day?*

20. On average how many hours do you sleep per night?*

21. How many days per week are you willing to exercise?*

22. Please provide detail of days to avoid with exercise & also your typical times of availability in each day to exercise *

23. Please provide an example of each days exercise in your typical routine & provide as much detail and clarity as possible *

23. Please provide an example of each days exercise in your typical routine & provide as much detail and clarity as possible *

23. Please provide an example of each days exercise in your typical routine & provide as much detail and clarity as possible *

23. Please provide an example of each days exercise in your typical routine & provide as much detail and clarity as possible *

23. Please provide an example of each days exercise in your typical routine & provide as much detail and clarity as possible *

23. Please provide an example of each days exercise in your typical routine & provide as much detail and clarity as possible *

23. Please provide an example of each days exercise in your typical routine & provide as much detail and clarity as possible *

24. Do you have any exercise equipment available at home whatsoever? Strength or cardio? (N/A if not applicable)*

25. Do you have any experience and history of jogging/running? *

YES

NO

26. Is there any reason why you feel that you would be unable to jog or run? *

YES

NO

27. Do you own a set of scales? *

YES

NO

28. Do you own a heart rate monitor? *

YES

NO

29. Do you own a sleep tracker device or app?*

YES

NO

30. Have you ever tracked your food intake in an app & monitored calories & macros ?*

YES

NO

FOOD DIARY

Please provide a very honest & accurate example of a typical day of eating

DO NOT portray an example that is not realistic or typical

Please try to include weights / measures or as a minimum a guide to serving size

‘IF’ you are able to provide accurate calorie & macro inputs please do so – If you do not have this information please leave empty

Time of waking*

Time

:HoursMinutes

Time of exercise*

Time

:HoursMinutes

MEAL 1

MEAL 1 - Time*

Time

:HoursMinutes

MEAL 1 - Description*

MEAL 1 - Calories

MEAL 1 - Carbs (g)

MEAL 1 - Protein (g)

MEAL 1 - Fats (g)

MEAL 2

MEAL 2 - Time*

Time

:HoursMinutes

MEAL 2 - Description*

MEAL 2 - Calories

MEAL 2 - Carbs (g)

MEAL 2 - Protein (g)

MEAL 2 - Fats (g)

MEAL 3

MEAL 3 - Time*

Time

:HoursMinutes

MEAL 3 - Description*

MEAL 3 - Calories

MEAL 3 - Carbs (g)

MEAL 3 - Protein (g)

MEAL 3 - Fats (g)

SNACKS

SNACKS - Time*

Time

:HoursMinutes

SNACKS - Description*

SNACKS - Calories

SNACKS - Carbs (g)

SNACKS - Protein (g)

SNACKS - Fats (g)

ALCOHOL INTAKE

Glasses / Units / Type*

ALCOHOL INTAKE - Calories

ALCOHOL INTAKE - Carbs (g)

ALCOHOL INTAKE - Protein (g)

ALCOHOL INTAKE - Fats (g)

TOTALS

TOTALS - Calories

TOTALS - Carbs (g)

TOTALS - Protein (g)

TOTALS - Fats (g)

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