Confirmation Page Round1

28 Day Challenge Form – Round1

LETS DO THIS BABES!

Name *

First

Last

Email *

Phone *

Date of Birth *

Age *

Height (cm) *

Current Weight (kg) *

EXERCISE & DIET

What are your short term training goals? *

What are your long term training goals? *

What do you want to achieve in this challenge? *

EG- 3kg weight loss, better energy, increased fitness etc

How many days per week CAN your do weight training and how long for? *

Do you feel faint or dizzy when exercising? *

Are you on any prescribed medications? Please list them below *

Are you currently taking any vitamins or supplements? *

Do you have any food allergies or dietary requirements? Please note the meal plan is set , this is for me to refer to and give you extra advice. *

Are there any foods you dislike? *

How easy is it for you to follow a nutrition plan? Scale of 1-10 ; 10 being easy *

CURRENT TRAINING

Do you currently undergo any type of fitness training? If so how often? (Choose one) *

I currently don’t train
Yes I train 1-2x per week
Yes I train 3-5x per week
Yes I train 6+ x per week

What type of training are you currently doing and how often/long ? (Be specific EG- Running 2x 30 mins, Yoga 1x , Weights 3x) *

What is your current daily activity levels? Choose One: *

Sedentary (Office job) Less than 5000 steps per day
Moderately Active (Teacher, retails etc 5000-8000 Steps per day )
Active (Hospitality, manual labour etc 8000-10000 steps per day.
Very Active 12000 + Steps per day

Is there anything else we need to know that may affect your training & nutrition plan? Be specific Eg- Pregnant, health concerns, injuries or recent surgeries. *

I understand I should get full doctors clearance before starting My Jess Coate Fitness Challenge *

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Lastly if you would like to send pics front side and back along with this info it may help me more with how I will prescribe the exercise. Please see PDF Attachments in introduction email on how to take your progress pictures.