Health Assessment

Its time to take your body to the next level.

Please fill this form out with as much information as possible once we have recevied this please allow 3-4 days, you will receive an email to let you know your plans are ready.

First Name

Last Name

Phone

Date of Birth

Height (in cm):

Weight (in kgs):

Address

Do you have any past medical history? if so please state :

Have you ever had surgery? if so please state including how long ago and any complications:

Are you currently pregnant or breastfeeding?:

Yes No

Have you ever experienced, or do you currently have, or being treated for an eating disorder?:

What is your blood type? (if known):

Do you currently take any vitamins and minerals? If so please list:

Are you currently taking any supplements? if so please list:

On average how many hours of sleep are you getting per night?:

Any known food intolerances? if so please list:

Any dietary requirements eg gluten free, vegetarian:

How long have you been training for?

Please provide a brief description of your current exercise regime (duration, style,times per week):

Any issues we should be aware of for your training plan? (past or present injuries):

Have you ever competed in a show before? if so when and in which federation:

Do you have a competition you would like to prepare for? if so which:

Give us a brief description of lifestyle. eg family, work,daily routines:

Please provide a statement with your goals so we can help you achieve these (eg weight loss, muscle gain, comp prep etc)

What made you sign up with Golden Legacy Coaching?

Anything else you feel we should know?

Health Assessment

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