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Pre-Screening Questionaire

The information in this appraisal questionnaire will be used to give you the best possible advice to suit your needs and ultimately the best results. All information is strictly confidential. Please be as accurate and detailed as you can with your answers so as to help us give you the best possible service.

The form may take some time to complete, if you would like to save the details and come back to complete the form, please scroll to the bottom of the page and click save, you will be asked to enter and email address for us to send a link to, you can then click the link to open the form and continue.

Personal Information

Name(Required)
Address(Required)
Activity Level
Gender
MM slash DD slash YYYY
Have you had online coaching before?(Required)
How did you hear about our coaching?(Required)

GOALS

What are you goals?(Required)
What time frame do you see yourself reaching this goal?(Required)
Rate your experience with Gym / Strength training(Required)
Rate your ability to perform a body weight Chin Up(Required)
Rate your ability to perform a Barbell Squat(Required)

BODY COMPOSITION

What are the body parts that may be lagging and you want to bring up and focus on?
Do you currently track steps , if so what is your daily average?
Do you have experience tracking food ?(Required)

HEALTH SCREEN INFORMATION

Please select the checkbox if the answer is yes to anything in the section below(Required)

GENERAL HEALTH

On a scale of 1 to 10 (1 being the lowest) please set the number below for each question.
Do you work shifts?

SLEEP HABITS

What time do you go to bed at night?(Required)
:
What time do you normally wake up?(Required)
:

DIET INFORMATION

Do you suffer from constipation or diarrhoea?
Please list any foods that you regularly crave
Do you feel you have any weaknesses when it comes to nutrition?
Do you experience any of these general symptoms every day?
Please select the checkbox if the answer is yes to anything in the section below

DAILY MEAL EXAMPLES

Please list below an example of your daily eating patterns

SUPPLEMENTS & MEDICATION

Please enter the name of the product, dosage, duration of usage, reason for taking the product, and if it helps?

FLUIDS

Please give your answer in litres

CURRENT DISCOMFORT OR PAIN

TRAINING

Briefly explain.
MM slash DD slash YYYY
Are you able to complete a weekly food diary on a regular basis?

LIABILITY WAIVER

I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with Perkins Training Having such knowledge, I hereby release Perkins Training, their representatives, agents, and successors from liability for accidental injury, illness or death which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in any program, indoors or outdoors, prescribed to me by Perkins Training and their representatives. I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in a fitness program to Perkins Training. PLEASE CHECK WITH YOUR DOCTOR OR SPECIALIST BEFORE EXERCISING.
The above information is correct and I understand that I should seek medical advice before starting an exercise program. I agreed to the term and conditions presented above.
This field is for validation purposes and should be left unchanged.