Initial evaluation

First Name *

First

Last Name *

Last

Birth Date

Age *

Height *

Weight (lbs)

Email *

Phone *

Goals

What describe best your fitness goal?

Why is that goal important to you?

What drives you? In ~1-2 short sentences, write a personal statement on why your goal is important to you. For example, if your goal is to Lose Weight and you have a specific weight in mind, why is that number important for your lifestyle? This is the Why that drives your coaching program. It will likely continue to develop along the way. (Every answer is a good answer.)

What's been getting in the way of your goals?

Are you exercising regularly? *

Yes

No

Exercise and Movement

If yes, how often and what types of exercise?

If no, when was last time you exercise and what type of exercise was?

Do you have any existing injuries or conditions that I should be aware of while building your training plan?

Yes, I have lower limb pain / discomfort

Yes, I have back pain / discomfort

Yes, I have upper limb pain / discomfort

No, I don't have pain or discomfort that would require a modified workout program.

If you have more than one area of restriction, please choose the option that requires the greatest modifications to your workout program. Let your coach know more of the specifics of the pain / discomfort that you feel related to movement and exercise.

Which of these best describes the lower limb pain / discomfort that you're experiencing?

Acute: I recently injured it and would like to find ways to work out around it.

Chronic: It’s been hurt for quite a while now and I’d like to find ways to work around it.

Exercise-induced: Specific types of exercise bother it and I’d like to find a program I can do without irritating it.

How would you describe the severity of your lower limb pain?

1: I typically have no pain.

2: I have some very mild pain that's usually barely noticeable. Most of the time I don't think about it.

3: I have some minor pain / I have occasional stronger twinges. It's annoying.

4: I have pain that's usually noticeable. I can get used to it and adapt.

5: I have pain that's noticeable, distracting, and it interferes with daily activities.

Which of these best describes the back pain / discomfort that you're experiencing?

Acute: I recently injured it and would like to find ways to work out around it.

Chronic: It’s been hurt for quite a while now and I’d like to find ways to work around it.

Exercise-induced: Specific types of exercise bother it and I’d like to find a program I can do without irritating it.

How would you describe the severity of your back pain?

1: I typically have no pain.

2: I have some very mild pain that's usually barely noticeable. Most of the time I don't think about it.

3: I have some minor pain / I have occasional stronger twinges. It's annoying.

4: I have pain that's usually noticeable. I can get used to it and adapt.

5: I have pain that's noticeable, distracting, and it interferes with daily activities.

Which of these best describes the upper limb pain / discomfort that you're experiencing?

Acute: I recently injured it and would like to find ways to work out around it.

Chronic: It’s been hurt for quite a while now and I’d like to find ways to work around it.

Exercise-induced: Specific types of exercise bother it and I’d like to find a program I can do without irritating it.

How would you describe the severity of your upper limb pain?

1: I typically have no pain.

2: I have some very mild pain that's usually barely noticeable. Most of the time I don't think about it.

3: I have some minor pain / I have occasional stronger twinges. It's annoying.

4: I have pain that's usually noticeable. I can get used to it and adapt.

5: I have pain that's noticeable, distracting, and it interferes with daily activities.

Any other comments about what you would like work on your training sessions?

Other than exercises, what else would you most like to work on to support your goals?

Nutrition

Stress

Sleep

non-exercise daily movement

Pelvic Floor Screening

This part to help identify if you may be at risk of pelvic floor dysfunction and allow me to safely plan your exercises.

Are you currently pregnant?

Yes

No

Have you recently (or ever) had a baby?

Yes

No

Are you going through or have been through menopause?

Yes

No

Have you ever undergone gynecological surgery (e.g., a hysterectomy)?

Yes

No

Are you an elite athlete (e.g., a runner, gymnast, or trampolinist)?

Yes

No

Do you have a history of lower back pain?

Yes

No

Have you ever injured your pelvic region (e.g., through a fall or pelvic radiotherapy)?

Yes

No

Do you experience constipation or regularly strain on the toilet?

Yes

No

Do you have a chronic cough or sneeze (e.g., because of asthma, smoking, or hayfever)?

Yes

No

Do you have a BMI over 25?

Yes

No

Do you frequently lift heavy weight (e.g., at work or at the gym)?

Yes

No

Accidentally leak urine when you exercise, play sports, laugh, cough or sneeze?

Yes

No

Need to get to the toilet in a hurry, and do you sometimes not make it there in time?

Yes

No

Constantly need to go to the toilet?

Yes

No

Find it difficult to empty your bladder or bowel?

Yes

No

Accidentally lose control of your bowel, or accidentally pass wind?

Yes

No

Have a prolapse (e.g., a bulge or feeling of heaviness, discomfort, pulling, dragging, or dropping in the vagina)?

Yes

No

Experience pelvic pain or pain during or after sex that involves vaginal penetration?

Yes

No