Plan Of Action

Complete Your Plan Of Action Below

Hey,

You’re ALMOST set up and ready to get started!

I am really excited to get started working with you.

Please complete your Plan of Action below. Completing your Plan of Action (Consultation Form) below will allow me to put a step-by-step, personalized, plan in place for you that will help get you the best possible results quicker than ever before.

Failure to complete, submit, and confirm your Plan of Action will delay the process and potentially set you back a couple of weeks in which you will not be reimbursed. So please get this section done ASAP. It’s your responsibility to get this done ASAP.

Complete Your Plan Of Action Below

Plan Of Action Form

Step 1 of 14

All information gathered in this consultation form will be kept private and confidential. Please provide as much detail as possible to all questions asked. If you feel like there is any additional information that would be of interest, outside of the personal questions, please include this as and when you see fit.

Personal Information

Name(Required)

First Last

Email(Required)

Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

MM slash DD slash YYYY

Have you got any pets? If yes, what are their names?(Required)

What is your Instagram name?(Required)

How would you like to receive your personalized coaching plan?(Required)

Detailed Text Message

Phone Call

Zoom Call

Please note if you choose a zoom call - I will send you a zoom link to join 24hrs prior to our agreed time to go through your coaching plan.

Current Body Weight

Lowest Body Weight (In The Last 12 Months)

Highest Body Weight (In The Last 12 Months)

Rate your experience with exercise:

Beginner

Intermediate

Advanced

Goal Setting

What have you tried in the past?

Has anything you tried in the past worked for you? If not, why?

What do you need from a coach?

What are your 3-month goals?

What are your 12-month goals?

Why are these goals important to you?

How do you know if you have achieved your goal(s)?

What is your indicator of progress?

Are you able to commit to achieving your goals?

What are the 3 biggest obstacles you face with these goals?

Medical History and Medications

Please list any relevant past medical history, i.e. food allergies/intolerances, high cholesterol, diabetes, heart disease, ADHD, hypo/hyperthyroidism, recent surgery, bowel disease, depression, eating disorders, recent athletic injuries, anaemia, etc.

Please list any current prescribed or non-prescribed medication.

Please list any past or current injuries.

Have you ever been diagnosed with an eating disorder?

Yes

Are you pregnant?

Yes

Do you have:

High Blood Pressure?

Yes

High Cholesterol?

Yes

Diabetes?

Yes

Have your parents or siblings had any of the following before the age of 55:

A heart attack?

Yes

A stroke?

Yes

High blood pressure?

Yes

High cholesterol?

Yes

Known heart disease?

Yes

Rheumatic heart disease?

Yes

A heart murmur?

Yes

Chest pain with exertion?

Yes

Irregular heart beat or palpitations?

Yes

Light headedness or fainting?

Yes

Unusual shortness of breath?

Yes

Cramping pains in legs or feet?

Yes

Emphysema?

Yes

Other metabolic disorders (thyroid, kidney, etc)?

Yes

Epilepsy?

Yes

Asthma?

Yes

Back pain: upper, middle, lower?

Yes

Other joint pain?

Yes

If you have answered yes, please explain.

Muscle pain or an injury?

Yes

Medical History and Medications – Female Physiology

Do you get regular periods?

Yes

Have you lost your period in the last 5 years?

Yes

At what age did you get your first period?

How long did it last?

When was your last period?

Do you suffer with premenstrual discomfort?

If you have lost your cycle, please outline the circumstances that led this to occur, when it occurred, and whether or not you have regained your cycle?

Do you notice any significant weight gain at certain points in your cycle? If so, is this accompanied by any significant/visible water retention?

Do you notice any changes in behaviour (food cravings/mood) and/or performance (strength/recovery) at any points in your cycle? If so, when?

Lifestyle

What is your occupation?

What level of physical activity does your occupation require?

Does your occupation require shift work?

Yes

If your occupation involves travel and/or hights away from home please give details

On average, how many hours do you sleep:

Weeknights

Weekend

Sleep

Do you have trouble falling asleep at night?

Yes

Do you have difficulty waking up in the morning?

Yes

If you wake up during the night, what time(s)?

1-3am

3-5am

Wake up tired at 5am

Many time throughout the night

Do you sleep in a room with any light or noise?

Yes

Do you wake up feeling tired?

Yes

Do you wake up only with an alarm?

Yes

Do you go to bed later than 11pm?

Yes

Do you get up earlier than 6am?

Yes

Do you use medications to help you sleep? (Note: this includes melatonin)

Yes

Do you feel your sleep is of high-quality?

Yes

Do you sleep in a room containing any artificial light sources (even very small ones)?

Yes

Training and Exercise

Do you use a pedometer?

Yes

If yes, please give your average daily step total:

Weekdays

Weekend

Are you willing to exercise 2-4 hours per week?

Yes

Do you currently have a gym membership?

Yes

If no, are you willing to get one?

Yes

Are you currently on an exercise program, or have you used a structured exercise program in the last 12 months?

Yes

If yes, what specifically are you doing each day (i.e. time of day, activity type, duration)?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Please indicate the physical activities that you participate in outside the gym and outside work?

Have you ever played sport?

Yes

If yes, which sport(s), when, and how long?

Are you currently working with a trainer or coach?

Yes

Review your experience, likes and dislikes?

Please could you list and particular exercises/movements that you really connect well with/enjoy/find it easy to progress?

Please could you list and particular exercises/movements that you do not really connect well with/enjoy/find it easy to progress?

If there are any days that must be kept as non-training days, please specify these.

Food, Nutrition, and Lifestyle

Check if you:

Diet often

Do not exercise regularly

Are under excessive stress

Are exposed to cigarette smoke

Are exposed to chemicals at work

How often do you cook meals from scratch?

How often do you eat meals out?

Are you vegetarian?

Yes

If yes, please list which foods you do not eat (i.e. chicken, fish, diary, eggs):

How many times do you go shopping per week?

Are you willing to prepare your food in advance and measure your food intake accurately?

Yes

How many times per week do you typically eat out per week? (Including restaurants and takeaways)

If you have any allergies, please list them below:

Have you followed a low calorie diet in the last 12 months?

Yes

If yes, please list below and say whether this is down to preference or an actual diagnosed intolerance:

How many litres of water do you consume per day? Is this consistent?

Are you willing to regulate your caffeine intake if you don’t do so already? If no, why not?

Are you willing to eliminate/minimise the presence of processed foods in your diet? If no, what are you not prepared to eliminate/minimize and why?

Roughly how many times per day do you consume wheat-based products?

Roughly how many times per day do you consume dairy products?

How many servings of fruits and vegetables do you consume per day (assuming 1 handful is a serving)?

Please list any trigger foods (foods that you find it very hard to resist eating that could potentially derail your dietary adherence).

How much do you spend on supplements per month?

Please list your current supplementation regime, if any?

On average, how many days a week do you consume alcohol?

On average, how many alcoholic drinks do you consume at one time?

What types of alcohol do you consume (i.e. beer, wine, spirits)?

On average, how many caffeinated drinks do you consume per day?

What types of caffeinated drinks do you consume (i.e. energy drinks, coffee, tea, carbonated drinks)?

Do you smoke tobacco products?

Yes

If yes, how many cigarettes per day?

End Goal/Result

Imagine we’re having this conversation 90 days from today and we’re looking back over the previous 90 days/12 months. What has to have happened, personally for you to be happy with your progress/results?

Other

Are there any questions you would like to ask before we get started?

Food Diary

Please provide a rough log of your nutrition for 3 separate days. The more detail here the better. These can be for the previous 3 days. This is to get a rough look at your nutrition.

Please give as much information as possible with regards to time eaten, food sources eaten, and quantities consumed.

This is a very important part of the application process, even if it is only for one day.

Food sources eaten and approximately or exact quantities and time consumed.

Day 1

MEAL / SNACK 1

FOOD

TIME

MEAL / SNACK 2

FOOD

TIME

MEAL / SNACK 3

FOOD

TIME

MEAL / SNACK 4

FOOD

TIME

MEAL / SNACK 5

FOOD

TIME

MEAL / SNACK 6

FOOD

TIME

Day 2

MEAL / SNACK 1

FOOD

TIME

MEAL / SNACK 2

FOOD

TIME

MEAL / SNACK 3

FOOD

TIME

MEAL / SNACK 4

FOOD

TIME

MEAL / SNACK 5

FOOD

TIME

MEAL / SNACK 6

FOOD

TIME

Day 3

MEAL / SNACK 1

FOOD

TIME

MEAL / SNACK 2

FOOD

TIME

MEAL / SNACK 3

FOOD

TIME

MEAL / SNACK 4

FOOD

TIME

MEAL / SNACK 5

FOOD

TIME

MEAL / SNACK 6

FOOD

TIME