Consultation form & disclaimer

Full name

Date

Address

D.O.B

Sex

Phone

Height

Current Body Weidght

Lowest B/W (Last 12 Months)

Highest B/W (Last 12 Months)

What are your nutrition and fitness/training goals ? If its holiday/photoshoot/competition or other specific event, please give detail to time frame or exact dates if known.

What have you tried in the past to achieve your nutrition and fitness goals? This includes any diet or exercise protocols, previous coaching, supplement use, books, etc.

Please list any current prescribed or non-prescribed medication:

Please list any past or current injuries:

Have you ever been diagnosed with an eating disorder?

Yes No

Are you pregnat?

Yes No

Do you have high blood pressure?

Yes No

Do you have diabets?

Yes No

Have your parents or siblings had any of the following before the age of 55?

A stroke?

Yes No

High blood pressure?

Yes No

High cholesterol?

Yes No

Know heart disease?

Yes No

Rheumatic hearth disease?

Yes No

A hearth murmur?

Yes No

Chest pain with exertion?

Yes No

Irregular hearth beat or palpitations? Light-headedness or fainiting?

Yes No

Unusual shortness of breath?

Yes No

Cramping pains in legs or feet?

Yes No

Emphysema?

Yes No

Asthma?

Yes No

Other metabolic disorders (thyroid, kidney, etc.? Epilepsy?)

Yes No

Other joint pain? Muscle pain or an injury?

Yes No

What is your occupation?

What level of physical activity does your occupation require?

Does your occupation involve shift work?

Yes No

If shift pattern is regular, do you work mornings, days or nights?

If your occupation involves travel/nights away, please give details:

How many hours do you sleep - Weekdays:

How many hours do you sleep - Weekends:

Additional comments:

If you wake up during the night, what time(s)?

1-3am 3-5am Wake up tired at 5am Frequently

Do you have trouble faling asleep at night?

Yes No

Do you have difficulty waking up in the morning?

Yes No

Do you sleep in a room with any light or noise?

Yes No

Do you wake up feeling tired?

Yes No

Do you wake up only with an alarm?

Yes No

Do you go to bed later than 11pm?

Yes No

Do you get up earlier than 6am?

Yes No

Do you use medications to help you sleep?

Yes No

Which foods make you feel uncomfortable after eating them, if any?

Do you suffer from indigestion of hearh burn?

Yes No

Do you suffer from belching or gas within one hour or eating?

Yes No

Do you have a sense of fullness after meals?

Yes No

Do you suffer from bloating 1 hour after eating?

Yes No

Do you suffer from bad breath?

Yes No

Do you have fewer than on bowel movemnt per day?

Yes No

Do your muscles become easily fatigued?

Yes No

Do you feel exhausted after moderate exercise?

Yes No

Are you stressed?

Yes No

If you are stressed - are you, and what are the main causes of stress in your daily life?

How do you manage your stress?

Have you seen a counsellor/therapist in the past?

If YES, please give deatils:

Do you smoke tobacco products?

If YES, how many cigarettes per day?

Do you have a pedometer?

Yes No

If YES - give daily average steps - Weekdays:

If YES - give daily average steps - Weekends:

How many times per week would you be able to commit to training session?

How many of these sessions, would you like to be a personal training session?

Do you currently have a membership in PureGym at Fort Kinnaird?

Yes No

If NO, are you willing to get one?

Yes No

Are there any specific days you'd like off?

Yes No

If YES, please give deatils:

What time of the day, would be best suited for the workouts?

Are you currently on an exercise program, or have you used a structured exercise program in the last 12 months?

Yes No

If YES, what specifically are you doing each day? (time of dat, activity type, turation, etc.)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Please indicate the physical activities that you participate in outside the gym and work:

Have you ever played a sport? If YES, which sport(s), when, and for how long?

Are you currently working with a trainer/coach?

Yes No

If YES, please give details on your experience, likes and dislikes:

Additional comments:

Please provide a sample log of nutrition for your average day. The more detail you can provide here the better.

Please give as much information as possible with regards to time eaten, food sources eaten and quantities consumed. If you use a calorie tracking app and are logging food, please list the total macronutrient totals for each meal, and the total calories and macronutrient totals for the day at the bottom of each log. If you workout on that day, please specify in the food column which foods were consumed around the workout window.

Please fill in using the following structure:

Food - Time - Macros (P/C/F) - energy before - energy after.

Food: sources eaten and approximate or exact quantities.

Time: time consumed

Macros (if known): gram of protein/carbs/fat

Energy levels: please include your energy levels before/after meal.

Meal / Snack 1

Meal / Snack 2

Meal / Snack 3

Meal / Snack 4

Meal / Snack 5

Are you vegetarian?

Yes No

If YES, please list foods you DO NOT eat (chicken, fish, dairy, eggs, etc.):

Are there any foods you dislike? (Please list)

How many times do you go food shopping per week?

Are you willing to prepare food in advance and measure your food intake accurately?

Yes No

If you have an allergies, please list them below:

Have you followed a low calorie diet in the last 12 months?

Yes No

If YES, please list below and say whether this is down to preference or an actual diagnosed intolerance:

How much do you spend on supplements per month?

Please list your current supplementation regime, if any?

On average, how many days a week do you consume alcohol?

On average, how many alcoholic drinks do you consume at one time?

What types of alcohol do you consume? (beer, wine, sprits, etc.)?

On average, how many caffeinated drinks do you consume per day?

What types of caffeinated drinks do you consume? (every drinks, coffee, tea, etc.)?

Additional Comments:

Please provide photographs for initial physique assessment. This will allow for posture analysis, body compositional status, lagging body part analysis and overall muscularity. These will be part of the monitoring process to ensure the plan is having the desired effect on the body.

Men: a pair of boxer shorts/briefs.
Female: bikini bottom/underwear, top/sports bra.

Please take these first thing in the morning (after the toilet, pre food/liquids). Each week, please ensure that these are taken at the time, in the same lighting and wearing the same clothes. No mirror selfies (use a timer on the front-facing camera), however we recommend getting a cheap tripod.

Please be state if you want all photos to be private and confidential otherwise, they may be used for Instagram purposes.

Upload your photos (.jpg / .png) - max 25mb all.

Additional Comments:

1. Trainer is not a medical professional and is without expertise to diagnose medical conditions or impairments. Client agrees to promptly and fully disclose to trainer any injury, condition or impairment which they have suffered in the past no matter how long ago and must notify the trainer if their physical condition has changed before any and every session.
2. Client certifies that a) he/she is physically capable of participating in a strength, flexibility, endurance, aerobic training exercise using the equipment associated with such training; b) he/she is over the age of eighteen (18); and c) he/she has consulted their doctor before participating in exercise or participates freely.
3. This training program will involve physical activity and, as appropriate, use of certain equipment and machinery. Client voluntarily agrees to participate in these activities and to assume all risk of personal injury, death and property damage resulting from activities.
4. Client agrees on behalf of him/herself and his/her personal representatives or heirs to release and discharge trainer, his agents, representatives, successors, and assigns from any and all claims or causes of actions (known or unknown) arising out of this training program including without limitation injury or loss resulting from client's use of any equipment or facilities which break or malfunction.
5. Client realises results are not guaranteed but will perform to their best ability in order to achieve their goals. They realise the trainer is not to blame.
6. Client accepts that no refunds will be given, no matter what stage of your block you're at.
7. Trainer retains the right to terminate this agreement for any reason including without limitation to clients failure to follow direction or conduct contrary to the interests of this agreement. This agreement may be executed in duplicate and a copy shall be considered as effective as original.
8. Trainer is not responsible for the safety or facilities or equipment used by client at any venue, please wear appropriate athletic footwear and loose comfortable clothing to facilitate ease of movement.
9. Proper nutrition and adequate rest are essential to this training program, client realises that any supplementation recommended by trainer, is taking voluntarily and at clients own risk.
10. New bundle have to be paid before the session, starting the block - in situation the payment is missed, that session will be treated as a single session, and the cost then is £50.
11. My cancellation policy is 24h - if You let me know that for some reason You can't attend a scheduled session, we can change it to a different time, yet if it's within less than 24 hours, it will be deducted from Your paid block.
12. Upon arriving over 15 minutes late to the session, without notifying myself of the delay, the session then is forfeited.

Client name

Date

I've read and agree with the above disclaimer.