Client Questionnaire – Mitropoulos Coaching Training & Nutrition

Which coach did you sign up to work wIth?*

Date*

Full Name*

First Last

Email*

Your Age*

Please enter a number from 16 to 100.

Phone*

Are you currently dieting?*

YES
NO

Current weight*

Please enter a number from 75 to 600.

Height*

Current goal(s)*

Gender*

Male
Female

Are you employed? If so, what is your occupation?*

YES
NO

Are you consistently following a set nutrition program?*

YES
NO

What is your current diet, nutrition? Provide further details about your eating habits? PLEASE BE AS SPECIFIC HERE AS POSSIBLE*

Are you maintaining, gaining, or losing weight on your current nutrition/ diet?

Maintaining
Gaining
Losing

In the past 2 years how much time have you spent in a calorie deficit or attempting to be in calorie deficit via “yoyo dieting”?

How many days would you prefer to workout per week? SELECT ONE (Think about sustainability and what you would be able to consistently commit to each week)

3 Days
4 Days
5 Days

When do you prefer to workout

early morning
late morning
afternoon
night

When do you prefer or able to do cardio?

Fasted in the morning (empty stomach before first meal)
Directly after workout
Doesn’t matter

Are there any specific days of the week you need to have OFF from workouts?*

How many meals do you eat currently?*

How many meals do you prefer to eat a day?

4
5
6

What meal number will be your pre-workout meal?*

Describe your daily schedule:*

Do you have any concerns regarding your digestion ? (ie: bloating, cramping, diarrhea, constipation, reflux, burping, etc…)*

Bowel movement frequency:

Less than 1x per day
1x per day
More than 1x per day

How much sleep do you get per night? SELECT ONE

Any allergies/intolerances to food or medication? If so, please list.*

Are you currently on any medications? If so, please list below (this includes if you have recently in the last month stopped any)*

Female clients- Are you currently on birth control medication? If so, what kind?*

Female clients- do you have a regular menstrual cycle)

Yes
No

Any current injuries I should be aware of? Any previous injuries or surgeries?*

Are there any foods you dislike, or won't eat?*

Are there any foods you would love to see included in your daily nutrition that would help you be more consistent in following your plan?*

Be realistic here --- examples: pasta, English muffins, cereal, bagel, wraps etc.

Do you have recent blood work results? (Within the last 2 months). If not, are you able to get blood work done?*

Do you currently use or have you in the last 3 months used PEDS? If so, please list…*

IF NOT PLEASE PUT NO OR N/A

Do you smoke tobacco products?

Yes
No

Do you drink alcohol?

Yes, occasionally
Yes, often
No

What do you feel is more important in achieving your goals? SELECT ONE

Motivation
Consistency

Are there any obstacles you're facing that may impede your success?*

***** By completing this questionnaire you acknowledge that you are required to give 14 days’ notice prior to cancelling services otherwise you will be required to pay per normal based on pricing agreement for the current month. ALL PLANS ARE REQUIRED TO A 3 MONTH COMMITMENT (payment for 3 months NOT due up front, only the first months payment is)

Add your name again below, as your signature and acceptance of this agreement*

First Last

Please Upload FRONT/BACK and SIDE photos of yourself so we can get started.

Drop files here or

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