Fit prescreening – 360 Life Changes

Hello, Fitness Bestie! Welcome to 360 life changes Fitness Coach prescreen. Take a few moments to Fill out the “Get Fit Questionnaire” and we will reach back out to you shortly after we review your responses. This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by 360 life changes for any loss, damage, or injury that may arise from any person acting on any statement or information contained in this tool.

Basic client information

Full Name

Sex

Date of Birth

Best time to contact you?

How did you hear about us?

Are you in school: What level

Do you currently work: Yes or No

Have you purchased the 360 Deck?

Part 1 Personal information: Full name

Gender

Male Female

Date of birth

Age

Height

Weight

Home Address

City

ZIP

State

Cell Phone

Home Phone

Part 2 Lifestyle information: What do you do for a living?

What’s the activity level at your job?

None (seated only) Moderate (light activity) High (heavy labor)

Do you follow a regular 9-5 working schedule?

Yes No

Do you work Days or nights?

DAYS NIGHT

How often do you travel?

Rarely A few times a year A few times a month Weekly

Please list the physical activities that you participate in outside of the gym and outside of work

Part 3 Medical and health information: Have you ever been Diagnosed with COVID-19 or have signs of COVID-19?

Are you on any medication that will hinder your workout performance?

If you are on any medications please list them

What additional therapies are being undertaken for the given health problems?

If you have any injures list them

What additional therapies are being undertaken for the given injury?

Are you experiencing any stresses or motivational problems?

Yes No

Has anyone in your family developed heart disease before the age of 60?

Yes No

Do any diseases run in your family?

Do you suffer from diabetes asthma high or low blood pressure?

If so please list

Are you a current cigarette smoker?

Yes No

What kind of diet will you be interested in while completing the program: Select down below?

Are you allergic to any foods? Please list.

Part 4 Coaching goals: Please rate your readiness for change (1. Not active/ Not Ready, 5. Active but need a boost, 10. Ready to get it on and popping)

What following goals best fit in with your goals?

What’s your goal with your fitness coach?

Why?

TimeLine for achieving goals

How often are you willing to train on your personal time to reach your goal?

Please type one motivational word that represents the level it takes for you to reach your goal. (Ex. Endurance, courage).

Are you currently exercising regularly? If yes what do you do currently?

Yes No

If yes what do you do currently?

Have you trained with a personal trainer or coach before? What was the outcome? Explain

Yes No

If yes what training did you do?

What did you not like about the training?

At what times during the day would you prefer to do the 1:1 fitness coaching or group fitness coaching?

Morning Mid-day Afternoon Evening

Are you currently on a diet? yes or no

Yes No

Explain (please add a sample)

How often do you want to commit to the 1:1 personal coaching or Group Coaching? (note: all programs are 5 days Monday-Friday. Saturday chit chat and Sunday Fitness card spread). Are you able to commit as outlined above? yes or no

What is your expectation of us as your fitness coach? Will you be able to make it to and from the workout station, as well attend digital workout? Will you be able to follow a diet plan or create a diet plan?

Do you know that this program is Fitness /Health coaching Program that means; you will have to do the work to achieve your goals and maintain your goals? Type ” yes I understand”

Part 5 : Why us? Why are you choosing the 360 life changes fitness program?

Which programs do you want to sign up for: Please add 1:1 personal coaching if you’re interested in personal coaching needs.

Sunny delight Earthy flower Moon Goddness 1:1 personal coaching

What is your goal for the program of choice?

What will you like to inform your fitness coach?

Are you able to complete 360 life changes fitness/ nutrition booklet by digital or physically downloads? yes or no?

Yes No

If no explain why?

The Fitness deck will be required before starting the program or you can purchase fitness card reading separately online until you receive your deck.

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GET IN TOUCH

Call: 1 (561) 389-5974
Email: Bestpart@360lifechanges.info

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GET IN TOUCH

Company number: 1 (561) 389-5974

Email: BestPart@360lifechanges.info

Address:
360 life changes llc
3469 W Boynton Beach Blvd
Suite 2 PMP 1011
Boynton Beach,Florida 33436