Intake form – Performacoaching

Intake ENGLISH

First name

Surname

Date of Birth:

Adres

Street and house number (addition):

Postal code and city

E-mail

Current health and medical history

Do you have injuries, physical complaints or medical conditions?

Yes

if so, which ones?

Do you take any medication?

Yes

if so, which ones?

Are you currently under the care of a doctor, therapist, or physiotherapist?

Yes

Experience & activity

Do you have experience with strength training or other sports?

No experience

Basic experience (1-2 x per week)

Advanced (3+ times a week)

If so, which sports?

What kind of work do you do?

Fysiek

Zittend

Onregelmatig

Objectives

What is your main goal? (Multiple answers possible)

To fall off

Building muscle mass

Become fitter/more energetic

Structure in lifestyle

Specific sports goal

Which sport?

Lifestyle & habits

How many hours do you sleep on average per night?

Do you wake up several times during the night?

Yes

How would you rate your energy level on a scale of 1 to 10 (1 = poor energy level 10 = high/good energy level)

Do you smoke?

Yes

Do you drink alcohol?

Yes

if so, how many glasses per week

Please indicate whether you consume the following meals?

Breakfast

Lunch

Evening meal

Do you drink enough (water)?

Yes

What is enough?

Coaching & guidance

What do you expect from me as a coach?

Planning

When do you want to start?

Welke tijden heeft jouw voorkeur om te trainen? (Meerdere antwoorden mogelijk – afhankelijk van beschikbaarheid)

In the morning between 8am and 12pm

In the afternoon between 12 and 4 pm

In the late afternoon between 4 and 8 pm

In the evening between 8 and 10 pm