Client Intake & Health Screen — Coach Jen Brockwell

About You

Full name * Email * Date of birth

Your Goal

What do you want your body to look and feel like? Your own words — not gym words. Where do you tend to store body fat? Do you weigh yourself or use a body scanner (BodyTrax/InBody)? Where are you now, where would you like to be? What period of your life did you feel the fittest and best ever — and what were you doing then? Do you have a specific goal in mind? What do you think is holding you back?

Your Training

How many times per week do you train? Where do you train? (tick all that apply) What does a typical week look like? List your usual classes/sessions. How long have you been training regularly? Do you do any cardiovascular training? If so, what's your preference? (tick all that apply) How often do you do cardio? Do you lift weights / resistance train? If so, what are your splits? (tick all that apply) How do you train? (tick all that apply) How often do you resistance train? Do you wear a Fitbit/step counter? Average daily steps:

Stretching & Mobility

What do you currently do for stretching and mobility, if anything?

Food & Drink

Do you follow any specific diet? (tick all that apply) What's the reason for this? (tick all that apply) If allergy or intolerance, please specify what — and how it affects you: This helps me keep you safe when advising on food. Roughly what did you eat and drink yesterday, waking to bed? What's your appetite like? e.g. "I'm hungry constantly," or "I can't face breakfast so I skip it" Do you have any food vices? e.g. reward yourself with a tub of Ben & Jerry's, always get a muffin with your coffee, can't say no to dessert, crash after lunch and reach for chocolate, nibble crisps and nuts when you drink How many times per week do you eat out or get a takeaway? Alcohol in an average week (e.g. 2 glasses of wine Fri + Sat) Caffeine per day (e.g. 2 lattes and 1 can of Coke) Supplements you take regularly e.g. "I take a multivitamin," "I add protein powder to my morning smoothie," "I take iron when I'm tired" Have you ever tracked your nutrition (calories/macros)?

Yes, and it worked for a while Yes, hated it Never

What have you already tried to change your body? (diets, programmes, PTs, apps — the lot)

Energy, Stress & Recovery

How would you describe your energy levels most days?

High energy Average Low Struggling

Do your energy levels vary day to day / week to week? What's the pattern? Hours of sleep on an average night — solid or broken? Stress score out of 5 (5 = maxed out) What do you do to relax? How do you approach recovery? (rest days, sauna, stretching, yoga-style movement...) How do you feel about exercise? (tick all that apply)

Health — Share Only What You're Comfortable With

Anything medical stays between us, and I may point you to your GP where something is beyond my scope.

Any injuries, health conditions or medications I should know about — including HRT? Are you, or could you be, pregnant?

Yes Possibly No

If you're post-natal — how many weeks or months since you gave birth, and have you had your 12-week check? Do you suffer with PMT? If so, what symptoms do you experience? Do you think you may be peri-menopausal or menopausal? If so, what symptoms are you noticing? Have you ever struggled with disordered eating or body image/body dysmorphia? This only changes how carefully we approach food — never shared, never judged.

Yes, in the past Yes, currently No Prefer to talk about it on the call

Lifestyle

Have you had children?

Yes No

What is your occupation? (desk, on your feet, shifts?) How active would you describe yourself?

How Ready Are You?

Would you say you're ready to make a change and commit to yourself?

Yes, completely ready Mostly ready, just need the right support Still thinking it over Not sure yet

What would you most like to improve?

My physique — how I look My health and fitness — how I feel and perform Both equally Not sure yet — we'll figure it out together

How You Work Best

Do you work best with a structured plan, or more autonomy?

Give me the plan Point me in the right direction Somewhere in between

In your gut — what do YOU think is stopping your body from changing? If our work together could give you just one thing, what should it be?

Health Screen (PAR-Q) — Required Before We Train Together

Standard physical activity readiness questions, required by my insurer before any new client begins remote coaching. Please answer honestly — a YES doesn't stop us working together; it just means we check with your GP first.

a. Has a doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No

b. Do you feel pain in your chest when you do physical activity?

Yes No

c. In the past month, have you had chest pain when not doing physical activity?

Yes No

d. Do you lose your balance because of dizziness, or do you ever lose consciousness?

Yes No

e. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes No

f. Is a doctor currently prescribing you medication for blood pressure or a heart condition?

Yes No

g. Do you know of any other reason why you should not take part in physical activity?

Yes No

If you answered YES to any question, please speak to your GP before we begin training — I may ask for confirmation that you're cleared to exercise.

If you answered YES to anything above, tell me a bit more here:

Before We Start — A Few Safety Basics

These apply to every remote session, required by my insurer:

Train in a suitable, non-slip space, clear of obstructions.
Wear suitable footwear for the session.
Don't use any blades, weapons, or sharp instruments during a session.
If anyone else is in the room, keep clear of physical contact and maintain distance from them during the session.
If you currently have, or suspect you have, any injury, ache, or health concern, tell me before we start rather than pushing through it.

Declaration

I confirm my answers above are honest and complete to the best of my knowledge. I understand I take part in remote coaching at my own risk, and that I should stop and seek advice if I feel unwell, dizzy, or in pain. I will tell Jen if my health, medication, or circumstances change. I consent to my coaching sessions being recorded and/or transcribed for coaching and record-keeping purposes. I understand recordings may be retained for up to 36 months in line with Jen's insurance requirements, and I can withdraw this consent at any time by telling Jen directly. (Optional — leave unticked if you'd rather sessions weren't recorded, and let Jen know on the call.) Full name, as your signature * Date *