Online Program Design Intake Form
Health and Wellness Profile
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Email *
Full Name *
Phone Number *
Birthday *
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Body Weight (pounds) *
Height (inches) *
How did you hear about us?
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Tell us a little about yourself?
The more we know about you the better we can design you a custom program. Tell us a little more about who you are.
What is it you really want to achieve through Online Program Design / Coaching? Why did you seek this service? *
What would you ultimately like to achieve by hiring us? The more detail the better, and we’re not just talking about surface goals — like weight loss — here. We really want to explore your deeper motivations (if there are some) and goals for hiring us.
What have you already tried before?
Have you tried anything in the past? Ie other programs, writing your own, etc? If so, what?
How's that working out?
Of the stuff you have tried before, how's it going now?
What does the perfect program look like to you? What does it include? *
Do you like tracking your weights? Seeing video demos for each exercise? Challenges throughout the weeks? Is there anything specific you'd like your programs to include?
What do you expect from working together with us?
What do you expect from your coach?
What do you think we expect from you?
What are you prepared to do to work towards your goals?
Please check off all that's important to you *
Please list all of your concerns about your health, eating habits, fitness, and/or body in "other section" if something is not listed here.
Required
How many days per week can you commit to training? Ie, how many days per week do you want your program to include? Or do you know what you should be doing? *
Have you worked with a Trainer before? *
Have you been a member of a gym before? *
Are you interested in a gym membership at ALP-TI in addition to your coaching program? (if local to the Hamilton, Ontario area) *
Please select the appropriate experience level you have with respect to weight training / exercise. *
Describe what your current (and most recent - 8 weeks) workout routine looks like. Includes some weights for major exercises. *
Include as much detail as you can think of.
Describe what your workout space looks like. *
What kind of space do you have and what equipment do you have access to?
Describe what your current supplement routine looks like on a weekly basis.
Include as much detail as you can think of.
Describe a typical day with respect to nutrition.
Discuss what you eat and drink from breakfast to bedtime, including medications. Point form is fine.
Describe a typical work day.
These include your daily actions (ie. 5am wakeup/shower, 530-630am breakfast/get ready for work, 630am-330pm at work, 330-4pm pick up kids from school, 5-6pm make dinner for family, 6-7pm eat dinner, 8-9pm go to the gym, 9-10pm watch tv/read a book, eat, etc)
Please describe any injuries you are currently dealing with or have had any major injuries previously.
Maybe you're dealing with a nagging back or knee injury, or maybe you have had some serious surgery or health complications we ought to know about. Anything additional to this questionnaire that you feel could help.
Please describe anything else you think we should know about you that could help design the appropriate program for you.
Maybe you travel a lot for your career. Or maybe you have had some serious surgery or health complications we ought to know about. Anything additional to this questionnaire that you feel could help.
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