eliteFITcoach.com: Fitness Client Startup

"Fitness Coaching" Start-Up Interview

(Please print out, complete and send to your coach.)

Basic Information

Name_______________________________________________________________________________

Street __________________________________________________________________Apt.__________

City ____________________________________________State________________Zip______________

Phone: Home (______)____________ Work (______)____________ Mobile (______)_______________

Best Place to call you__________________________________________________________

Best Times to reach you________________________________________________________

Fax (______)____________ E-mail Address______________________________________

Gender ________M________F

Birthday ______/______/______ Age ______ Weight ______Height______

How do you prefer to receive workouts? On-line_____ Fax_____ E-mail_____ At 1-on-1 meetings_____

For which focus/sport(s) do you want coaching?

____Fitness for Healthy Living ____ Golf "Fit To A Tee"

____Sport of_________________ Other, Please specify ________________________

How did you hear about eliteFITcoach? Referred by__________________ Website________

Other_______________________(please clarify)

Which Coaching Plan option have you selected?_________________________________________

Occupation _______________________________ Hours worked weekly_________

Same hours each week?_____ Very stressful?_______ Stressful?________ Not Stressful?_______

Hobbies _________________________________________________________________________

Married? _______ Spouse's Name________________

Children?_______ If yes, what age(s)?_________________________________________________

What kind of support do you have from family/friends in helping you reach your goals?

__________________________________________________________________________________

Your Athletic and Fitness History

1. List your favorite sport/fitness activity and years of participation.

Sport/Fitness Activity Years Comments

_____________________ ___________ ____________________________________________

2. How many years have you worked out for fitness?___________

How many years have you done strength training?______________

3. Have you ever had an exercise-related injury which caused you to stop exercising for a week or more? Please describe.

_______________________________________________________________________________________

4. Athletes, please list your best competitive results.

Events Results

________________________ ____________________________________________________

5. Are there any other accomplishments you would like me to know about?

______________________________________________________________________________________

Your Goals

1. What are your three most important goals? Please list by priority.

1. _________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

2. What obstacles do you think must be overcome to reach your goals? (ie: time, schedule, weight, etc.)

______________________________________________________________________________________

3. What are the main motivating factors for you in getting fit?____________________________________

______________________________________________________________________________________

4. What commitments are you willing to make to reach your goals? Please list 3 and be specific.

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

5. What is the single most important thing we must accomplish together?

______________________________________________________________________________________

6. Goal Events

List (in order of importance) any events in which you plan to compete, along with realistic goals for each.

Event Date Goals

_____________________________ _____________ ______________________________________

Your Current Fitness Schedule

1. Rate your current fitness level (1=worst shape, 10= best shape)____________________________

2. Do you keep a workout log?______ If so, please submit a typical workout week.

3. What kind of workouts and sports participation have you been doing for the past 3 months?

_________________________________________________________________________________

__________________________________________________________________________________

4. How many days per week do you: workout for general fitness?___________

run, walk, or ride?________ play golf?______ other (please specify)________________________

5. Your strength training. Type: ___Nautilus ___Universal Gym ____Free weights _______ Other (specify)

Briefly describe your current strength training routine (days per week, sets, reps, resistance).

______________________________________________________________________________________

6. How often and how much time do you spend stretching?______________________________________

_______________________________________________________________________________________

7. Please describe your current diet and your understanding of nutrition?____________________________

________________________________________________________________________________________

8. Do you have a teaching pro/coach?______ If so, who is it?________________________________

9. What areas of your fitness or sport need the most improvement?___________________________

__________________________________________________________________________________

10. What kind of workouts do you enjoy the most?______________________________________

__________________________________________________________________________________

11. List your available hours to workout each day (ie. 5:30-7:00 am, 6:00-8:00 pm, I'm flexible):

Mon.______________________ Tues.______________________ Wed.______________________

Thurs.____________________________________ Fri.____________________________________

Sat.____________________________________ Sun._____________________________________

12. Do you own a Heart Rate monitor?______ What is the maximum Heart Rate you've

seen working out?______ What were you doing?_________________________________________

Do you know your resting pulse (taken in the a.m.)?_________

Medical

1. Are you currently under the care of a physician? Yes _____ No _____

If yes, please explain: ____________________________________________________________

_______________________________________________________________________________

2. Are you taking any medication? Yes _____ No _____

If yes, please list: _______________________________________________________________

______________________________________________________________________________

3. Have you had a complete physical in the last year? Yes _____ No _____

Weight________ Ideal Weight_______ Height__________ %Body Fat______________

4. Smoke? Never____ Quit over a year ago ______ Quit less than a year ago _______

Currently smoke _______

5. Please mark with an X all of the following that apply to you. Please explain in the space

provided, or on a separate sheet:

_____Have you or anyone in your family had coronary artery disease?

_____Have you ever fainted or felt dizzy after exercise?

_____Has a doctor said that your blood pressure is too high?

_____Do you have heart trouble, a heart murmur or have you had a heart attack?

_____Have you ever had a complete physical exam, including stress test on a treadmill or ergometer?

When?______________Please attach a copy of your results.

6. Do you ever have chest, shoulder, neck or arm pains during exercise? Yes ____No____

7. Are you diabetic, have a thyroid or any other chronic condition? Yes____ No ____

8. Is your cholesterol level high? Yes____ No____

What is your cholesterol count? ________ What is your HDL level?____________

9. Are you now or have you been pregnant in the last three months?

Yes_______ No_________

10. Have you ever had a joint or back disorder or any current injury? Yes____ No_____

If so, please explain_____________________________________________________

____________________________________________________________________

11. Have you had surgery in the past 12 months? Yes____ No__________

If so, for what?________________________________________________________

____________________________________________________________________

12. Do you have any conditions that your doctor says may limit your physical activity?

Yes______ No______

If so, please explain____________________________________________________

____________________________________________________________________

13. Do you have any conditions that you think may limit your physical activity?

Yes______ No______ If so, please explain__________________________________

____________________________________________________________________

*Please consult your physician before starting this or any exercise program.

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Client Waiver and Release

Your signature is required

I have been informed of and acknowledge that participation in strength, flexibility and aerobic exercise, (cycling specific activities included) including the use of equipment, is a potentially hazardous activity. I also have been informed of and acknowledge that participation in fitness activities, use of equipment and machinery and/or participation in an endurance sports events can be an extreme test of a person’s physical and mental limits and such training and participation poses potential risks of serious bodily injury and death, or property damage. I HEREBY AGREE TO EXPRESSLY ASSUME AND ACCEPT ALL RISKS OF INJURY OR DEATH.

Please initial_____________

I agree to the following (initial statement to which you agree at the "initial" space):

(Initial)_________eliteFITcoach, LLC has been retained to assist me in the improvement of my fitness and/or cycling.

(Initial)__________I hereby attest that I am in good health and suffer no condition, impairment, disease, infirmity or other illness that would prevent my participation in these activities or use of equipment or machinery. I acknowledge that I have been informed of the need for a physician’s approval for my participation in the fitness activities. I attest that my physical condition has been verified by a licensed medical doctor.

(Initial)__________In consideration of being accepted as a client by eliteFITcoach, LLC, I hereby take the following action for myself, my executors, administrators, heirs, next if kin, successors and assigns, or anyone else who might claim or sue on my behalf:

a) Waive, Release, and Discharge Kim Morrow, eliteFITcoach, LLC and eliteFITcoach’s directors, employees, administrators, consultants, coaches and agents from any claims, costs or liabilities for personal injury, illness, death or damages of any kind which I may have now, or at any time in the future, resulting from participation in this or any other program or from use of any equipment at various sites, including home, provided by and/or recommended by eliteFITcoach, LLC.

b) Agree not to Sue any of the persons or entities mentioned above for any claims, costs or liabilities that I have waived, released or discharged herein.

c) Indemnify, Defend, and Hold Harmless, the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

(Initial)_____I am solely responsible for my debits and agree to pay for services no later that the first day of each 4-week coaching period. I agree to pay collection fees if my debits are 15 or more days overdue. I understand that my initial Client Start-Up Fee, Complete Fitness Assessment Fee and current month’s coaching fee is non-refundable. It is my responsibility to initiate phone calls to my coach and I will pay for any long distance phone charges.

(Initial)_____I am retaining Kim Morrow, eliteFITcoach, LLC to coach me at a rate of _________per month. (One month equals 4 weeks). I understand that my commitment is for ________ months from the dates______________ , 20_____ to _________________, 20____.

(Initial)____I affirm that I am eighteen (18) years of age or older, I have read this document and understand its contents.

Printed Name: ___________________________________

Signature: ______________________________________ Date:___________________________

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PLEASE return this from with your Client Start-Up Fee of _______________ and first month's coaching services payment of______________ payable to: Kim Morrow, 100 Bromsgrove Drive- Suite 7, Greenville, SC 29609. (You also have the option of sending your payment via the eliteFITcoach.com website).

Your coach will inform you as to which fees are applicable.

You will then be contacted to clarify any information, set up your coaching strategy session or to complete the fitness assessment. After this process has been completed, you will be given a start-up date to begin your first month of coaching together. Thank you for taking the time to fill out this information. We look forward to working with you!

Any questions? E-mail Kim: kim@eliteFITcoach.com