WHAT YOU DON’T KNOW ABOUT COACHING & TRAINING WOMEN
GGS-1 Client Intake Form
DAY
1
PLEASE FILL OUT THIS QUESTIONNAIRE TO HELP YOUR COACH LEARN MORE
ABOUT YOU.
More About You
Full name:
Date of Birth (mm/dd/yyyy):
Age:
Gender:
Pronouns:
Please describe your current family dynamic/living situation. Are you single?
Partnered? Do you have children? Pets? Other live-in family or roommates?
How do you spend your time / what do you do for work?
What are your favorite hobbies (if you have any)?
What is your favorite thing about yourself (physical, mental, personality, etc.)?
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P1
Day 1: GGS-1 Client Intake Form
What do you believe are your biggest strengths?
What fills you up and brings you joy?
Setting Boundaries
Throughout our coaching partnership, there may be things that come up that
you are or are not comfortable talking about. Topics such as your menstrual
cycle (or lack thereof), pelvic floor health, nutrition, sleep, and stress may all
have an impact on your training and your results to varying degrees.
Please indicate which topics you are comfortable talking about with me as
your coach by checking the box. If you are not comfortable talking about
these with me, leave the box blank. (Please note you may change your
decision at any time).
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Menstrual cycle
Pelvic floor health
Incontinence
Pelvic organ prolapse
Menopause
Nutrition
Eating habits and behaviors
Sleep
† Stress
† Emotional issues (e.g.,
depression, anxiety)
† Body image
† Weight
† Other (please list) _____________
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For the remainder of this questionnaire, you’ll be asked about several topics,
including some from the list above. If you’re not comfortable talking about
these, simply write “Opt out” in the space designated for your answer.
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P2
Day 1: GGS-1 Client Intake Form
Lifestyle
How much sleep do you get in a 24-hour period?
How much water do you drink per day?
What does your nutrition look like on a “typical” day? Please list meals and
approximate serving sizes:
Rate your stress level on a scale of 1-10 (1=little, 10=extreme):
Please describe your working environment if you are working (e.g., work
from home, flexible working hours, demanding employer):
Please describe your home environment (e.g., supportive, pressured, busy):
How do you feel emotionally? Do you ever feel anxious or have mood swings?
What are your physical goals over the next six months?
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P3
Day 1: GGS-1 Client Intake Form
Medical History
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR KNOWLEDGE.
Number of pregnancies:
Delivery type (Vaginal/Assisted/C-Section):
Do you have a previous history of injury, pain, or physical limitations with
any body parts? If so, please explain:
Have you ever had surgery? If so, when and what:
Do you have a bone or joint problem that could be aggravated by engaging
in physical fitness testing? (Yes, No, Unknown)
If yes, please explain:
Are you currently experiencing or have you recently experienced any
muscle or joint pain? (Yes, No, Unknown)
If yes, please explain:
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P4
Day 1: GGS-1 Client Intake Form
Do/have you experienced any of the following?
MUSCULOSKELETAL
† Pain in the central pubic area
† Lower back pain or sciatica
(if so, explain where)
† Neck pain
† Coccyx damage or pain
† Knee pain
† Any other joint pain
(e.g., wrist)
PELVIC HEALTH
† Heaviness, dragging, pressure,
or bulging in the pelvic area
† Diagnosis of pelvic organ
prolapse (uterus/bladder/
rectum/vagina)
† Hysterectomy
† Leaking urine when you
cough, sneeze, exercise, etc.
† Pain in perineum during
sexual intercourse (or any
other time of day)
† Unexplained bleeding during
or after exercise
URINARY
† Strong and sudden urge to
urinate
† Urinating more than 8 times
per day
† Feeling unable to empty your
bladder fully
† Discomfort or difficulty in
passing urine
† Uncontrollable gas
† Leaking of feces
† Straining during bowel
movements (constipation)
OTHER
† Hemorrhoids/varicose veins/constipation
† Gestational diabetes
† High/low blood pressure
If you checked yes to any of the above, please state when this occurred and
provide any relevant details you think we need to know:
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P5
Day 1: GGS-1 Client Intake Form
Have you met with any of the following healthcare professionals recently?
† Physiotherapists (Yes, No, Unknown)
† Acupuncturists (Yes, No, Unknown)
† Chiropractors (Yes, No, Unknown)
Please describe the approximate dates and reasons for your visit(s):
Medical Conditions
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR KNOWLEDGE.
Do you have or have you ever had asthma? (Yes, No)
Have you recently been ill or injured? (Yes, No, Unknown)
If yes, please explain:
Are you currently taking any physician-prescribed medications for the
following conditions?
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Heart / cardiovascular
Blood pressure
Hormones
Breathing / lungs
Insulin
Other medication for diabetes
Arthritis
Depression
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Anxiety
Thyroid
Ulcers
Pain
Allergies
None of the above
Other
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P6
Day 1: GGS-1 Client Intake Form
Do you now have or have you ever had (check all that apply):
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Coronary heart disease
Heart attack
Coronary artery surgery
Angina
High blood pressure /
hypertension
Peripheral vascular disease
Stroke
Diabetes
Thyroid problems
Arthritis
Hepatitis
Gout
† Chronic & severe headaches
† Head injury or epilepsy
† Abdominal pain, hernia, or
gastrointestinal bleeding
† Kidney problems or
discomfort when urinating
† Tend to bleed or bruise easily
† Anemia
† Lung problems
† Liver problems
† None of the above
† Other _________________________
Please list any prescribed medications you take / frequency / dosage:
Please list any over-the-counter medications you take / frequency / dosage:
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P7
Day 1: GGS-1 Client Intake Form
Clearance for Physical Activity
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR KNOWLEDGE.
Has a doctor ever said that you have a heart condition and recommended
only medically supervised physical activity? (Yes, No, Unknown)
If yes, please explain:
Do you have chest pain brought on by physical activity? (Yes, No, Unknown)
Have you developed chest pain in the last month when not doing physical
activity? (Yes, No, Unknown)
Do you lose your balance because of dizziness, or do you ever lose
consciousness? (Yes, No, Unknown)
Has a doctor ever recommended medication for your blood pressure or a
heart condition? (Yes, No, Unknown)
Are you aware of any reason (through your own experience, a doctor’s
advice, or anything else) that you shouldn’t engage in physical activity?
(Yes, No, Unknown)
If yes, please explain:
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P8
Day 1: GGS-1 Client Intake Form
Physical Activity
ANSWER THE QUESTIONS BASED ON THE ACTIVITIES YOU HAVE PARTICIPATED IN
DURING THE LAST 6 MONTHS. ALSO ESTIMATE THE AVERAGE NUMBER OF TIMES,
DURATION, AND INTENSITY OF EACH ACTIVITY.
During a typical week, what types of activity are you currently engaging in
and how often?
Do you intend to continue these activities during our coaching (for example,
do you still plan to attend a yoga or CrossFit class)?
How hard would you describe the intensity of your current exercise?
† Extremely light
† Very light
† Light
† Somewhat hard
† Very hard
† Extremely hard
What types of training have you done in the past five years, if any? Did it
help you achieve the results you were looking for?
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P9
Day 1: GGS-1 Client Intake Form
Please give a brief lifetime history of your physical activity.
(For example, I swam and played soccer from age 5 until 15. Then I was completely sedentary until I was
30, when I tried to take up running. I did a half-marathon, but it was really hard on my knees. I had lots
of pain, so I took up swimming again. Now I do it twice a week for 60 minutes when I can.)
Where you will be completing your workouts? Check all that apply.
† Gym
† Home
† Travel/hotel gyms
† Park/outdoors
† Other _________________________
What types of equipment do you have access to? Check all that apply.
No equipment
Dumbbells
Kettlebells
Barbells & weight plates
Squat rack
Cables and pulleys
TRX or similar suspension
straps
† Resistance band
† Swiss ball/physio ball
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† Jump rope
† Pull-up station
† Weight machines (please
specify which equipment below)
† Cardio machines (please
specify which equipment below)
† Limited access to equipment
(please specify which
equipment below)
† Other _________________________
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P10
Day 1: GGS-1 Client Intake Form
Additional Equipment Details:
How much time can you realistically devote to your workouts? Please
explain briefly.
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P11