Welcome toGet Fit Mastery Club Please complete this form to start Get FIt Mastery Club Initial AssessmentFirst NameMiddle NameLast NameDate / TimeTell me more about yourself.By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs.Date of birthGender- Select -MaleFemaleHeightCurrent WeightPlease print clearly.EmailMobileHome PhoneHow do you wish to communicate- Select -EmailVoice callWhatsappVideo callOther (Please specify)Emergency Contact NameEmergency contact phone numberWhat do you want to achive? In general what are your goals? Check that applyLose weight/ fatGain weightMaintain weightAdd muscleImprove overall healthImprove physical healthLook betterFeel betterHave more energyHealthy agingGet control of eating habitsGet strongerImprove athletic performanceGet off or decrease medicationPhysique competitionWhat do you want to change?How, specifically, would you like your habits, your health, your eating and/ or your body to be different?Out of all the changes you’d like to make, which ones feel most important/ urgent?Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/ or your body? If yes, what?Which of these things worked well for you, and why? (Even just a little bit, and even if you might not be doing them right now)Which of these things didn’t work well for you, and why not?If you were to consider making more changes to your habits, your health, your eating, and / or your body what would those be?Until now, what has blocked you or held you back from changing these things?Out of all the changes you’d like to make, which ones feel most important/ urgent? 1 Horrible 10 Awesome 1 2 3 4 5 6 7 8 9 10Why?Are you regularly active in sports and / or exercise? If so, approximately how many hours per week? Fewer than 5 hours 5-9 10-14 15-19 20 or moreWhat types of sports and / or exercise do you typically do?Approximately how many hours a week do you do other types of physical activity? (e.g. housework, walking to work or school, home repairs, moving around at work, gardening) Fewer than 5 hours 5-9 10-14 15-19 20 or moreWhat other types of movement and / or activities do you do?What’s around you?Who lives with you? Check all that apply.Spouse or partnerRoomate(s)ChildrenPet(s)Other family (e.g. parent, grandparent, sibling, etc, )Do you have children? If yes, how many and what are their ages?Who does most of the grocery shopping in your household? Check all that apply.MeSpouse or partnerRoomate(s)Child(ren)Other familyWho does most of the cooking in your household? Check all that apply.MeSpouse or partnerRoomate(s)Child(ren)Other familyWho decides on most of the menu / meal types in your household? Check all that apply.MeSpouse or partnerRoomate(s)Child(ren)Other familyRight now, how much do the people and things around you support health, fitness, and / or behavior change? 1 Not at all 10 Completely 1 2 3 4 5 6 7 8 9 10Have you ever been diagnosed ( currently or in the past) with any significant medical condition(s) and / or injuries? Yes NoRight now, do you have any specific health concerns, such as illness, pain, and / or injuries? Yes NoRight now, are you taking any medications, either over-the-counter or prescription? Yes NoOn a scale of 1-10, how would you rank your health right now? 1 2 3 4 5 6 7 8 9 10Why?How are you spending your time?In an average week, how many hours do you spend… In paid employment At school or doing school work? Traveling and / or commuting? Taking care of others? (e.g. children, person with a disability, older person) Doing other unpaid work? (e.g., housework, errands) Volunteering?Adding up all these things, how many total hours per week do you spend doing all these activities?On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness? 1 2 3 4 5 6 7 8 9 10How is your stress and recovery?Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best as you can:Given all the demands of your life, what is your typical stress level on an average day? 1 2 3 4 5 6 7 8 9 10On average, how many hours per night do you sleep? 4 or fewer hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 or more hoursHow do you normally cope with your stress?How ready, willing, and able are you to change?How do you normally cope with your stress?How READY are you to change your behaviors and habits? 1 Not at all 10 Completely 1 2 3 4 5 6 7 8 9 10How WILLING are you to change your behaviors and habits? 1 Not at all 10 Completely 1 2 3 4 5 6 7 8 9 10How ABLE are you to change your behaviors and habits? 1 Not at all 10 Completely 1 2 3 4 5 6 7 8 9 10What do you expect?What do you expect from me as your coach?What are you prepared to do to work towards your goals?What do you expect? Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision. Submit Form
