WaterCoach Home Questionnaire

Client Details
Client First Name:
Client Surname:
Email (required):
Client Registration Number (required):
Contact Tel:
Date of Birth:
Height:	inches cms
Weight:	lbs kgs
Sex:
Body Fat:
Occupation:
Smoker:	Smoker? yes no , if yes, how many per day
Drinker:	Drinker? yes no , if yes, how many per day
Medical History
Do you suffer from:
Heart Disease
Asthma
Diabetes
High Blood Pressure
Major Surgery	, if yes, supply details,
Other Ailments	, if yes, supply details,
Are you on Medication	, if yes, supply details,
Exercise History
Exercise Sessions per week:
Exercise duration per session:
Exercise intensity:	1- Easy 2 3 4 5 6 7 8 9 10- Hard
Do you do other exercise? If Yes, please provide details:
How long have you been exercising regularly (months)
Do you have a heart monitor?:
Dietary Habits
How many times a day do you eat?:
Are you a vegetarian?	yes no
Do you et fresh fruit and vegetables everyday?	yes no
How many times a week do you eat fast food?:
Aims and Goals
What are your aim and goals;
Maintain/Reduce Weight
Aerobic Exercise
General Fitness
Reduce Stress
Improve Strength
Reshape your body	, what body part,
Sport Specific	, what sport,
Would you like a weekly outline or a few rowing session ideas?	weekly outline rowing session ideas