0438 520 219 | 3/373 Glen Osmond Road, Glen Osmond, SA 5064 myintrinsicmind@gmail.com
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Yoga, Pilates, PT Session – Questionnaire

Please fill out the form below for your 1:1 Session

 

    Occupation

    Emergency Contact Name *

    Emergency Contact Telephone*

    What are your goals and expectations of this Personal 1:1 training with Leisa? IE what areas would you like to see change/focus on?*

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

    Have you practiced Yoga asana before?*

    If yes, please describe (style, regularity, duration, studio/home etc.)

    Have you practiced Meditation before?*

    If yes, please describe what meditation.

    Have you practiced breath work or pranayama?*

    If yes, please describe what kind of pranayama

    Have you practiced Hot Pilates/Pilates before?*

    If yes what style, studio or home

    Do you participate in other physical activities/exercise programs?*

    If yes, please list, what activity, how often and duration.

    How would you rate your health?*

    Why do you rate your health at that level?

    How would you rate your ME Time?

    How much time are you willing to spend on you?*

    Personal Health (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)? *

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

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

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

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

    If yes, please describe

    Do you or did you ever smoke?*

    If yes to smoking - how often/many?

    Do you take recreational drugs (including alcohol)?*

    If yes, please provide detailed informaiton (when, alone/social, type etc).

    General and Specific Health (please click on drop down and/or comment when appropriate and write 'P' if in the past)

    Eye Conditions:*

    Eyes - Other Details

    Allergies - Other Details*

    Sinuses

    Circulatory:*

    Circulatory: Other Details

    Respiratory:*

    Respiratory: Other Details

    Immune:*

    Immune: Other Details

    Digestion:*

    Renal:*

    Renal: Other Details

    Reproductive:*

    Reproductive: Other Details

    Muscular skeletal:*

    Muscular Skeletal: Other Details

    Skin:*

    Skin: Other Details

    Neurological:*

    Neurological: Other Details

    Mind:*

    Mind: Other Details

    Others (recent surgeries, diabetes etc)*

    Other Comments:

    Do you have a medically diagnosed condition under the care of a GP or Specialist?*

    If so, has your doctor provided clearance for you to participate in this program?*

    Additional Information - If yes to Doctors clearance please supply a copy of a medical certificate from your doctor.

    Are you on any Medication*

    If yes, please list below, prescribed medications and/or supplements, name of medication and dose.

    Family Health History

    Family Health History:*

    Family History Comment

    Are there any particular stress triggers in your life?*

    Stress Triggers Comment

    Do you have any particular concerns in your life at present?*

    What are your Concerns?

    Is there something in particular you wish to change or work on?*

    List what you would like to work on or change

    Please provide any additional information you might feel useful for this program.

    Any additional information for instructor attention:

    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 with Leisa*


    Please type your name in full below.

    Date*

    3/373 Glen Osmond Road,
    Glen Osmond, SA 5064

     

    Jen 0406 939 090
    Leisa 0438 520 219

    myintrinsicmind@gmail.com

    Skype: intrinsic_mind

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