Name
Email
Contact Number
Occupation
Age
Current Weight (lbs)
Target Weight (lbs)
Body Fat (If known)
What work/education hours do you work where you will be unavailable?
What work/education hours do you work where you will be unavailable?
What work/education hours do you work where you will be unavailable?
What work/education hours do you work where you will be unavailable?
What work/education hours do you work where you will be unavailable?
What work/education hours do you work where you will be unavailable?
What work/education hours do you work where you will be unavailable?
Is majority of your time at work spent seated, walking, lifting or other?
Other
Lifting
Walking
Seated
Do you have any current injuries/ medical conditions?
Are you pregnant, or recently have been?
Do you have any allergies food intolerances?
Do you have any past injuries that restrict you in any way?
Where do you personally feel you store the majority of your body fat?
Describe your energy levels right now? On a scale of 1-10
How “healthy” do you feel right now? On a scale of 1-10
How do you see yourself physically, where you want to be right now? On a scale of 1-10
What are your short term goals? (Choose 10))
What are your short term goals?
What are your short term goals?
What are your short term goals?
What are your short term goals?
What are your short term goals?
What are your short term goals?
What are your short term goals?
What are your short term goals?
What are your short term goals?
What are your long term goals? (12 weeks)
How did you hear about Coach Cauldwell?
Word of mouth
A friend
Facebook
Website
Are finances for food an issue?
List the foods you like or don't mind eating?
List the foods you don't like and will not eat?
Where do you generally shop for your food?
Do you prepare meals for other family members, such as children? Will this affect the way you eat?
Do you drink alcohol? If so how much?
No
Yes, once a month
Yes, once a week
Yes, 2-3 times a week
Yes, 5+ times a week
Other
Do you smoke? If so how many per day?
No
Yes, 1-4 a day
Yes, 5-10 a day
Yes, 10+ a day
Other
How would you describe your current energy levels and ability to concentrate?
Do you suffer with stress?
What time do you go to bed?
Do you struggle with sleep?
How long till you fall asleep?
Do you wake up through the night? If so, please state how many times
What time do you wake up?
How do you wake up?
Naturally
From Daylight
From Alarm/Phone
Do you have children/animals that effect sleeping patterns?
FEMALES ONLY; Do you have regular menstrual cycles? If so when?
How would you describe your current eating patterns?
How confident are you preparing meals, structuring meals with different food sources and knowing difference between proteins, fats and carbs?
Superb
Good
Average
Not great
Poor
How much caffeine do you consume on a daily basis?
How much water in litres do you consume on a daily basis? (Bottled, Filtered or Tap?)
How many meals would you be happy to consume?
List any previous “fad” diets you may have followed (Eg; Herbalife, Weight Watchers etc
List any supplements you take? And is budget for these a problem?
Describe your current training routine, including classes, cardio, weight training, outdoor activities etc
Describe your current training routine, including classes, cardio, weight training, outdoor activities etc
Describe your current training routine, including classes, cardio, weight training, outdoor activities etc
Describe your current training routine, including classes, cardio, weight training, outdoor activities etc
Describe your current training routine, including classes, cardio, weight training, outdoor activities etc
Describe your current training routine, including classes, cardio, weight training, outdoor activities etc
Describe your current training routine, including classes, cardio, weight training, outdoor activities etc
Are you enjoying your current routine?
Do you have any exercises you like, please state why?
Do you have any exercises you dislike, please state why?
Do you play and sports or compete at any level?
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