Coaching Consult Form - Root2Rise Fitness

Initial Consultation Form

I would love to get to know you a little better before our consultation call. Please answer the following questions:

Name *

First

Last

Phone *

Email *

What is your Age? *

What is your Weight? *

What is your Height? *

What is your Occupation? *

What are your Hobbies/Recreational Activities?

Do you have any food allergies? *

Are you currenty on any medications (outside of vitamins and supplements)? *

What have your past experiences with weight loss or gain been? Please tell me your story:

What forms of exercise have you practiced in the past month? *

	I haven't in the past month	< 4x a month	4 - 10x a month	10 - 20x a month	> 20x a month
Aerobic (cardio)	Aerobic (cardio) I haven't in the past month	Aerobic (cardio) < 4x a month	Aerobic (cardio) 4 - 10x a month	Aerobic (cardio) 10 - 20x a month	Aerobic (cardio) > 20x a month
Balance Training (Yoga, Tai Chi, Pilates, etc.)	Balance Training (Yoga, Tai Chi, Pilates, etc.) I haven't in the past month	Balance Training (Yoga, Tai Chi, Pilates, etc.) < 4x a month	Balance Training (Yoga, Tai Chi, Pilates, etc.) 4 - 10x a month	Balance Training (Yoga, Tai Chi, Pilates, etc.) 10 - 20x a month	Balance Training (Yoga, Tai Chi, Pilates, etc.) > 20x a month
Endurance (increasing periods of time of activity)	Endurance (increasing periods of time of activity) I haven't in the past month	Endurance (increasing periods of time of activity) < 4x a month	Endurance (increasing periods of time of activity) 4 - 10x a month	Endurance (increasing periods of time of activity) 10 - 20x a month	Endurance (increasing periods of time of activity) > 20x a month
Flexibility (Yoga, Tai Chi, etc.)	Flexibility (Yoga, Tai Chi, etc.) I haven't in the past month	Flexibility (Yoga, Tai Chi, etc.) < 4x a month	Flexibility (Yoga, Tai Chi, etc.) 4 - 10x a month	Flexibility (Yoga, Tai Chi, etc.) 10 - 20x a month	Flexibility (Yoga, Tai Chi, etc.) > 20x a month
Strength Building (body/weight lifting, Pilates, anything building muscle/bone strength)	Strength Building (body/weight lifting, Pilates, anything building muscle/bone strength) I haven't in the past month	Strength Building (body/weight lifting, Pilates, anything building muscle/bone strength) < 4x a month	Strength Building (body/weight lifting, Pilates, anything building muscle/bone strength) 4 - 10x a month	Strength Building (body/weight lifting, Pilates, anything building muscle/bone strength) 10 - 20x a month	Strength Building (body/weight lifting, Pilates, anything building muscle/bone strength) > 20x a month

Overall, At what intensity have you been exercising in the past month? *

Do you experience any pain when exercising? *

Please tell me on average, how many times do you eat in a day? *

What foods do you prefer to eat on a daily basis? *

What are your favorite indulgence foods? (You seldom have it, but it's a treat when you do.)

Who does the cooking in your household? *

On average, how many hours of sleep do you get a night? *

How much stress are you currently experiencing? *

	Very Low	Low to Moderate	Moderate	High	Extremely High
My Stress Level	My Stress Level Very Low	My Stress Level Low to Moderate	My Stress Level Moderate	My Stress Level High	My Stress Level Extremely High

If you chose moderate or higher, what are the main contributors to your current stress level?

Do you feel your loved ones will support you if you choose to make changes in your lifestyle? *

When you think about a lifestyle change on your journey to health, which emoji best describes you? *