Health Screening Form

Name*

First Last

Date of Birth*

Email*

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code Country

What's your current weight?

(I'll only use this to calculate an estimate of your daily energy requirement when we discuss nutrition)

If you have a target weight in mind, what is it?

How many hours per week do you currently exercise?*

Please detail whether you go to a gym, or if you workout at home what equipment you have available to you.

So I can put together a training plan that best suits your needs, please let me know what a typical week looks like for you, and how you plan to fit in the training plans that this programme gives you.*

Finish this sentence: In the next month I want to achieve…*

Do you have any injuries or illnesses that could affect you exercising?*

Please list any injuries or illnesses that have required the attention of a physical, psychological or medical practitioner. Please include the duration of each instance.

If you currently use medication for a condition or illness please state it here (including inhalers):*

Please advise the name of your registered doctor's surgery and name & address of any other health professional you are currently under the care of:*

If you are a smoker please state how many cigarettes you currently smoke per day.

Please use this field to tell me anything about your physical or medical history that could present an issue when taking part in exercise. I am here to support you and help you improve your health - so include anything here - nothing is 'too small’.*

Training presents a few risks, especially as I can't be there to monitor your form - to this effect, all exercise is done at your own risk and you should consult your doctor if in any doubt - please check AGREE to confirm you agree to these terms.*

I agree

Setting Up Your Workouts

In order to set up your training programme through my App, I need to know a bit more information. (I'm sorry if we've already chatted through this on the phone, but it's really helpful for me to have all your info in one place!)

Which days of the week would you like workouts scheduled for? (You don't have to stick to these days, the workouts will always be available for you to go back to)*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Where will you be working out? E.g. at the gym, at home, outside etc.*

What equipment will you have available to you? (This is particularly important if you're at home - and if the answer is 'none' that's fine, there's loads we can do with just your bodyweight!)*

How long would you like your workouts to last? Try to be realistic about the amount of time you have, no need to answer with what you think I want to hear!*

Is there anything else you'd like me to know?*

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Setting Up Your Workouts

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