Getting Started Worksheet

This worksheet is designed to help me get to know you and your fitness & lifestyle goals more intimately. Please respond to each section. Feel free to use as much space as you need to answer each question completely. The more detail I have, the better! All information will be kept confidential.

Once I receive your completed worksheet, I’ll review it and use it as a basis for our kick-off assessment session. If you have any questions along the way, please feel free to email me at Annette@AgelessWithAnnette.com or call (831) 204-8204.

Basic Contact Information

Name:

Email:

Mailing Address:

Phone:

Time Zone:

Connection Preference Information

Our coaching sessions will be done via the web. You will need to have a laptop or tablet and one of the following (free) apps uploaded to your computer. Please choose which virtual platform you prefer for our coaching sessions and provide your contact info:

Google Hangout:

Skype:

FaceTime (Apple users only):

Basic Health Information

Birthdate:

Gender:

Height:

Current Weight:

Has your weight ever fluctuated? By how many pounds?

List any Prescription Medicatins that you take:

List any Vitamins/Supplements that you take regularly:

Please indicate any additional pertinent health information:

Pre-Participation Health Screen

Has your doctor ever told you that you have heart trouble? (If yes, please explain below)

Do you frequently have pain in your heart or chest? (If yes, please explain below)

Do you often feel fait or have severe spells of dizziness? (If yes, please explain below)

Has you doctor ever told you that your blood pressure is too high or too low?

Do you have high cholesterol?

Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggrevated by exercise or may be made worse by exercise? (If yes, please explain below)

Are you over the age of 65 and not accustomed to vigorous exercise?

Explain any of your "yes" answers above or describe any other physical reasons that you may be unable to follow an activity program.

*Note: if you answered YES to one or more of the above questions, it is strongly recommended that you obtain your physician's approval prior to beginning a progressive exercise program.

About Your Fitness and Lifestyle Goals

What specific fitness and/or lifestyle goal did you have in mind when you signed up for persnalized coaching?

What is your single biggest challenge with regards to:

Fitness:

Eating:

Health:

Aging:

What is your biggest fear or frustration in your life right now related to:

Fitness?

Eating?

Health?

Aging?

What would you like to change/make better?

What is the biggest result you want to have in this area?

What would help you achieve this result?

How much time are you willing to invest toward achieving this result?

What has kept you from achieving this result?

Describe how you will look and feel when you achieve this result?

Informed Consent

By signing this document, I acknowledge that I have voluntarily chosen to participate in a coaching program that will include progressive physical exercise. I fully understand that physical exercise can be strenuous. I accept all responsibility for my health and any resultant injury or mishap that may occur from not following the coaching guidelines. I hold harmless of any responsibility, the coach or any persons involved with this program.

By signing this document (type in full name), I acknowledge that all coaching sessions will be paid in advance and that any cancellations with less than 24-hours notice will not be eligible for a refund.

Full Legal Name:

Date Signed:

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