Date of Birth

What are your goals and expectations of this coaching? What areas would you like to see changed?*

Personal Wellness (please click on drop down and/or comment where appropriate)

How would you rate your level of commitment (5 being excellent and 1 being poor)? *

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How would you rate your level of stress (5 being very High to none and 1 being very Low)? *

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How would you rate your level of fitness (5 being excellent and 1 being poor)? *

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How would you rate your personal motivation (5 being very high and 1 very low)? *

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Do you follow a specific diet? vegetarian, vegan, raw etc. *

YesNo

If yes, please describe

What do you really value in life*

What is stopping you from being successful in dealing with your challenges? *

Have you experienced NLP or Hypnotherapy? If yes, briefly describe the experience *

Did you ever smoke?*

No NeverI used toYes, DailyYes, but only socially

Additional Comments Welcome

Personal Health (please click on drop down and/or comment when appropriate)

Are you on any Medication*

YesNo

If yes do you have the doctors go ahead*

YesNo, not needed, I give consent

Please indicate if you have any of the conditions listed below

Allergies and AsthmaActive infectious disease (ex fever, cough etc)CancerCervical Spine ProblemsHerniaPregnancyRheumatoid ArthritisRecent Surgery

Coagulation & Platelets

HemophiliaAnticoagulant therapy - Coumadin, Warfarin or HeparinOther platelets or coagulation

Cardiovascular Disease

Brain or aortic aneurysmsHeart DiseaseHigh Blood PressureStrokeDeep Vein Thrombosis

Joint Problems

FracturesPrevious Dislocations

Soft tissue contraindication

Open wounds and cutsSkin Disease

Other, Please Describe

Do you hold any TENSION in your body, if so where?

Do you have any NUMBNESS in your body, if so where?

Do you have any MOVEMENT RESTRICTIONS for us to be made aware of, if so where?

Do you have any CRAMPING in your body, if so where?

Do you have any PAIN in your body, if so where?

Do you have any additional comments that you would like to inform your Practitioner prior to your appointment?

I consent that the above is relevant and correct information.

I have read, completed and understood everything within this questionnaire. All questions were answered truthfully and to the best of my ability. It is understood that the purpose of this coaching is to assist the client in achieving their goals. I have informed my coach about my state of my health and I have transmitted to them any recommendations and restrictions on the part of my medical doctor or therapist insofar as Personal Training is concerned.

I hereby consent to my coaching session*

YesNo

Date*