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Questionnaire

CAN WE HELP YOU?

 

**please read the notes below before continuing**

This is an opportunity to schedule a phone consultation to help me get to know YOU and YOUR goals.

I only work with those who are ready to take action today and see results each day thereafter.

Are you ready to level up your life, feel empowered, gain self-confidence and look great through sustainable lifestyle changes involving exercise, nutrition and mindset??

If so, this is YOUR first step to taking action towards cultivating the life of your dreams!

Client Consultation

PERSONAL DETAILS
All information supplied is kept confidential and will never be shared or passed on.
FULL NAME:*
YOUR BEST EMAIL ADDRESS:*
AGE*
SCALE WEIGHT*
HEIGHT*
HOW ARE YOU FEELING RIGHT THIS MINUTE?*
HOW HEALTHY DO YOU CURRENTLY FEEL?*
On average how many hours do you sleep per night?*
On a scale of 1 (low) to 10 (high) how would you rate your stress level?*
List your 3 biggest sources of stress: *
Please describe any medications or prescriptions you take on a regular basis, what it is for, and how it effects your ability to exercise.*
Have you ever experienced a rapid heartbeat, SOB or palpitations?*
Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis?*
Do you have diabetes, hypertension, or high blood pressure?*
Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:*
Any other medical conditions or healyh problems?*
Job title and what it involves on a day to day basis*
Do you know if you have/had an eating disorder? Or have you ever been clinically diagnosed - For example, anorexia, bulimia, rumination, OFSED or orthorexia?*
Have you suffered with anxiety and/or depression?*
NUTRITION ANALYSIS
This section looks at your current diet and eating habits. Please be truthful and accurate with your answers.
PLEASE DESCRIBE YOUR CURRENT NUTRITION KNOWLEDGE LEVEL*
Please describe any previous diets that you have followed, how successful they were and how you felt during them. Eg. Paleo, low carb, weight watchers, intermittent fasting etc.*
Please describe what your favorite healthy food choices are. Include what your favorite protein, carbohydrate and fat source is Eg. Tuna, Pasta and Eggs.*
Please highlight any foods you do NOT like:*
Please describe any allergies and/or intolerances you may have:*
Do you take dietary supplements? If yes, list them below.*
Please describe your goals in relation to a nutrition program.*
To date, what is the main factor(s) holding you back from achieving your nutrition goals?*
Please provide a timetable with your most normal daily schedule listing the time you wake up, work and have breaks, eat, work out and go to sleep:*
Do you ever binge eat?*
Would you say you have a good relationship with food?*
Please Describe an average day's eating for you. (Breakfast, Snack, Lunch, Snack, Dinner)*
Please Describe an average day's drinking for you. (Water - Ltrs, Tea/Coffee - Cups, Other - Juice/Fizzy drinks, alcohol drinks)*
PHYSICAL ANALYSIS
Physical training covers all aspects of fitness you conduct.
On a scale of 1 (worst ever) to 10 (best ever), how would you rate your current level of fitness?*
How many times per week do you typically take part in physical activities?*
Please describe what current training/sport you do (if applicable) Eg. Weight Training/Cardiovascular exercise/*
What training have you done in the past? How has it worked for you? *
Please describe your goals in relation to a physical training program.*
To date, what is the main factor(s) holding you back from achieving your training goals?*
What is your ultimate goal? Size, shape, tone or weight?*
What are you prepared to do to achieve these results? Diet, training, lifestyle?*
How many times per week would you like to train?*
How long do you have available to spend on each training session?*
Do you have any equipment at home, like weights, bands, etc?*
Do you prefer to exercise in Gym or at Home?
ON THE END
After coaching with me you should never need another coach again. You will learn everything you need to know to make lasting changes to your relationship with food, fitness and your mindset. This is an intensive programme of 1-2-1 bespoke coaching; you will be working day to day with your personal coach. I need you to be willing to commit emotionally, practically and financially to this life changing journey for a minimum of 3 months. Tell me why you are ready to commit:*
My powerful coaching programme will help you learn everything you need to know to make lasting changes to your relationship with food, fitness and your mindset. I work closely with you on a personalised 1:1 basis. Knowing this, are you ready to financially commit to finally getting the health results, achieving food freedom and ultimately, feeling happier?*
At the end of your free consultation call, if I think you’re ready and a good fit I will offer you a place on my 1:1 coaching programme. If you feel coaching with me is right for you, are you able to make a decision on the call to invest and secure your place on the programme?*

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Thank you for visiting my site!

My name is Kristina Perestegi

I`m a Personal Trainer, Advanced Body Pump instructor, Advanced Grit instructor, Exercise to music instructor, Hard Body coach, and Zumba instructor!

You can find me on Facebook, Instagram, and YouTube as well…

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