Home
Contact
CONTACT US
Nutrition-Alchemist-Consultation-Form
Consultation Form
Contact Us
What country do you live in?
What is your occupation?
How active are you at work?
Fitness Goals
Appearance
Cardiovascular Endurance
Flexibility
General Health
Self Esteem or Confidence
Speed
Sports Performance
Stress Reduction
Toning & Shaping
Weight Loss
Posture
New Option
Other Fitness Goals ( if not selected above)
Do you exercise regularly?
Rate your ability to perform cardio exercise
Rate your experience with exercise
What gym equipment do you have access to?
Full gym access
Free weights (dumbells/barbells)
Gym Machines ( Nautilus, Precor, Cybex, etc)
Cable Weights
Resistance bands
Bosu Balls
Kettlebells
TRX Bands
Bowflex
On which days are you able to work out?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How much time daily do you have to exercise?
At what time would you prefer to excercise?
AM
PM
THE STATE OF YOUR HEALTH
Upload File
Do you have any existing injuries or conditions that I should be aware of while building your training plan?
Do you experience any physical discomfort when training?
Do you experience any issue with your blood pressure, either high or low?
Do you presently suffer with any flu or chest infections?
Do you know your fasted glucose levels?
Do you know where your fasted lipids are sitting presently? nope
Do you smoke tobacco products?
Any other comments about what you would like to see in your fitness plan?
Do you have any food allergies?
Please list your allergies?
Do you take any medication? - Please list the medications you are taking
Have you had any surgeries or procedures and if so which and when?
If you are a woman are you planning on falling pregnant and if so when?
I apologise for this question, but it is important to understand that weight shift around this period can account for
Rate your stress levels?
GENERAL
Upload File
Which foods do you enjoy and would want to see on your eating plan to make it easier to adhere to the plan
Which foods do you like to eat on weekends?
How much time do you have to prepare and eat food?
How simple would you like me to make your eating plan?
Which foods would you prefer to avoid if possible?
What is your occupation?
How much time do you spend in the sun daily?
Do you drink alcohol? if so how much weekly?
Are you presently taking supplements or performance enhancing drugs and if so which ones?
Have you taken any performance enhancing drugs in the last 12 months and if so which ones
Are you willing to use supplements to achieve your goals?
When would you prefer a snack on your plan?
Are you okay with us using your images to showcase your hard work, if we ask for your permission first?
Opt-In
Yes I have
No I haven't
What else would you like to include to assist your trainer with your plan?
By submitting this document you confirm that the information in this form is comprehensive and complete and you understand and agree that the recommendations that will be made in relation to your nutrition and exercise regiment, will be based on the information provided. Should any of the details on this document change, you will need to update us so that we may make any necessary changes to your training or nutrition. General Statement of Program Objectives and procedures: I understand that this personal training program may include exercises to build the cardio respiratory system (heart and lungs), the musculoskeletal system, (which involves muscular endurance, strength and overall flexibility), and to improve body composition (increasing muscle and bone density and decreasing body fat) Exercise includes aerobic activities, such as walking, running, bicycle riding, rowing machine, group aerobics, swimming and other aerobic activities, weight lifting using dumbbells, machines and other equipment to improve muscular strength and endurance, as well as flexibility exercises to improve range of motion. Description of Potential Risks: I understand that the reaction of the heart, lung, blood vessels as well as other systems to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during the following exercise, which include abnormalities of blood pressure or heart attacks as well as other side effects. Use of weightlifting equipment and engaging in heavy body calisthenics may lead to musculoskeletal strains, pain and injury if adequate warm-up, gradual progression, and safety procedures are not consistently followed. I understand that personal trainer (seller) shall not be liable for any damages arising from personal injuries sustained by client (buyer) while and during and/or from a personal training program does so at his/her own risk. Client (buyer) assumes full responsibilities for any injuries or damages which may occur during and/or after training. I hereby fully and forever release and discharge personal trainer (seller), its assigns and agents from all claims, demands, damages, rights of action, present and future therein. I understand and warrant, release and agree that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging in active or passive exercise that will be detrimental to heart, safety, or comfort, or physical condition if I engage or participate (other than those items fully discussed on the health history form). I state that I have had a recent physical check-up and have my personal physician’s permission to engage in aerobic and/or anaerobic conditioning. Description of Potential Benefits:I understand that a program of regular exercise for the heart, lungs, muscles, and joints has many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function and decrease in heart disease. I have read the foregoing information and understand it. Any questions, which may have occurred, have been answered to my satisfaction.
I agree
Name
Phone number
Email Address
Thank you for contacting us.
We will get back to you as soon as possible.
Oops, there was an error sending your message.
Please try again later.
Get in touch with me
Call Me
Save My Contact
Home
Contact
067 074 6409
Web </> Design by:
Get Your FUTR
Share by:
