Pre Screening Form • Sami Rose

Please feel free to add as much detail as you can, so I can get to know your needs as best as possible!

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Client Details

Full Name*

Preferred name/nickname*

Email Address*

Phone Number for WhatsApp check-ins/chats*

Date Of Birth*

Select Date ×

Current Age*

State/Country*

Main goal(s) for coaching*

(list what you'd like to work on here!)

Occupation*

Daily activity level at work/school *

Sedentary (sitting most of the day)/Moderately Active/Very Active

How did you hear about my programs/services?*

Do you have any friends/family who have worked with me?*

Do you want to include weight/waist measurement in check ins, or would you prefer a completely non-aesthetic/non-diet approach? *

If so, please list current/last known stats:

General health/fitness levels

Please rate your current DIET out of 10*

(10 being most healthy/balanced)

Please rate your current TRAINING LEVEL out of 10 *

(10 being most fit/strong)

Are you currently working with or have previously worked with a registered Dietitian/Nutritionist?*

If so, please list any personalised recommended protocols

Are you currently seeing a personal trainer that you want to continue with during our coaching?*

If so, please list frequency/any relevant info

Are you currently seeing any professionals such as Physio/Chiro for injuries?*

Are you currently seeing any other medical professionals in relation to health/fitness?*

Do you currently smoke? *If yes, I would recommend quitting/cutting back!*

Do you regularly drink alcohol? *If yes, please note average amount of drinks per week:*

Have you ever been diagnosed with/suspected you have an eating disorder (anorexia/bulimia/BED/orthorexia/other)*

If so, please provide diagnosis/treatment details or any relevant info:

Please describe an overview of your history with dieting/weight loss/fitness challenges:*

Do you suffer from, or have been previously diagnosed with:

Chest Pains or family history of heart disease*

Yes

Osteoporosis/Osteopenia (weakening of bones)*

Yes

Myocardial infarction, Bypass graft, Valve replacement, Atrial fibrillation*

Yes

Amenorrhoea (irregular or absent menstrual cycle)*

Yes

Anaemia (low iron/b12/haemoglobin)*

Yes

Diabetes*

Yes

PCOS*

Yes

Endometriosis*

Yes

Thyroid issues including Hypo/Hyperthyroidism/Grave's disease*

Yes

Dizziness/fainting*

Yes

Asthma Attacks or difficulty breathing*

Yes

Recent Stroke or family history of stroke*

Yes

Low blood pressure*

Yes

High blood pressure*

Yes

High Cholesterol*

Yes

Arthritis or poor rotation in joints*

Yes

Lower back pain*

Yes

Any injuries/persistent muscle or joint issues*

Yes

Have you recently (within the last 12 months) been admitted to hospital?*

Yes

Have you recently (within the last 12 months) had any surgeries?*

Yes

Are you currently pregnant or have recently given birth (within the last 6 months)?*

Yes

Do you currently take any prescription medication(s)?*

Yes

Do you have any other health concerns, mental illness, injury or condition not mentioned above?*

Yes

*If you answered "YES" to any of the above, please add details here:

*All injuries/illnesses/conditions MUST be cleared with your GP/Doctor prior to commencing this program

SELF ASSESSMENT

Select the one that applies*

	None	Mild	Moderate	Severe
	None	Mild	Moderate	Severe
Non-Refreshing sleep or more tired/sluggish than normal
Brain fog/difficulty concentrating/poorer memory than usual
Loose, runny or explosive stools
Constipated more often/bloating/hard stools
Repeated weight loss and regain (other than normal fluctuations)
Feeling colder than others
Known infertility/reproductive/hormonal issues

*If you answered moderate/severe to any of the above, please add details here:

Nutrition Information

On average, do you currently eat less than 2 serves of protein per day?*

Yes

On average, do you eat less than 3 serves of fruit/vegetables per day?*

Yes

On average, do you drink less than 2 litres of water per day?*

Yes

Do you have experience tracking macros?*

Yes

Are you Vegetarian?*

Yes

Are you Vegan/Plant-Based?*

Yes

Have you followed a specific diet/meal plan recently? Please detail below (including calorie/macro targets if relevant):*

Please describe your current eating habits, ie what foods you would normally eat in a "typical" day:*

Are there any foods you avoid eating, or struggle to eat/have in the house without over-indulging?*

Describe your current relationship with food (ie do you struggle with binge eating, restrict from certain foods etc):*

Have you been diagnosed with food Allergies/Intolerances/Sensitivities? (i.e. dairy, nuts, please list)*

Fitness Information

On average, how many hours per week would you estimate you currently exercise?*

Where will you be excercising? *

(ie Gym/Home/Outdoors, or a combination)

If you will be using a gym-based program, are you comfortable using some machines, or mostly free weights?*

If training at home and/with limited equipment (other than a standard gym), please list equipment available to you:*

Please describe your current training routine (type of exercise if any, frequency, intensity, training style etc)*

If you have any injuries/limitations, are there any exercises you have difficulty with that you'll need to avoid/substitute?*

Do you currently track your steps? If so, how many would you average per day?*

Are you experienced in the following lifts?
If so, please list approx weight used for 6-10 reps:

Barbell Squats*

Barbell Deadlifts*

(Conventional or Sumo)

Shoulder Press*

Your Health + Fitness Goals

Non-Aesthetic goals (ie balance/consistency with health + fitness without specific body changes)*

Yes

Improve cardiovascular fitness levels*

Yes

Improve strength*

Yes

Improve flexibility/co-ordination*

Yes

Improve technique/try new lifts*

Yes

Manage mental health issues*

Yes

Reduce body fat*

Yes

Gain Muscle*

Yes

If you'd like to elaborate on any specific goals, add details here:*

Do you have a timeline/deadline for any of these goals?*

If you have other specific fitness goals ie specific strength targets, list them here!*

How many sessions per week would you ideally like to exercise*

(I generally recommend between 3 and 5)

Training Availability

Indicate your availability/preferred training days*

	Yes	No
	Yes	No
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Desired/Preferred Training Styles to be included

Select below*

	Yes	No
	Yes	No
Strength-based weight training
Circuit Style weight training
HIIT/Intense Cardio
Walking/low intensity cardio
Group Fitness Classes (please list)
Yoga/Pilates
Running/Jogging
Team sports/other activities for movement

When you think of your ideal life + health/fitness routine in 6-12 months, what would this look and/or FEEL like?*

When you think of your ideal relationship with food + your body in 6-12 months, what would this look and/or FEEL like?*

Anything else you'd like to add (notes, more info about you, specific requests for training/nutrition) please list here!*

Emergency Contact Details - Name, contact number, and relationship (this will only be used in case of an emergency!)*

CONFIDENTIALITY + CONSENT AGREEMENT*

By completing this questionnaire, I confirm that this program is for my own personal use, and will not be distributed to friends, family, other trainers/coaches or otherwise. This program and all its contents including bonus files, recipes and any information posted within the Sami Rose Fitness forum or during progress check-ins are owned by Sami Rose Fitness and no part of this program or its information can be reproduced, stored, transmitted or shared in any form, including email, photocopy, screen-shots, recording or otherwise. Sharing this program to a person/social media profile/site who has not purchased the guide is in violation of copyright, and if found to be in breach of said copyright, you may be pursued with legal action for this violation under the Copyright Act. By agreeing to this I acknowledge that I will abide by the confidentiality agreement both during my time as a client, and afterwards/ongoing. I also acknowledge the risks of online personal training - including but not limited to : self-managing injury risk prevention, correct form inclusive of warm up routines, following instruction, and seeking assistance where required (via video form checks through Sami Rose, or seeking help from a face to face trainer). I understand that Sami Rose Fitness cannot be responsible if I become injured due to incorrect form, and should I have any concerns about the safe/correct execution of any movement I will request examples from Sami Rose, and send video form checks to ensure I am completing exercises safely and correctly.

Type your full name here

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CONFIDENTIALITY & CONSENT AGREEMENT

By completing and submitting this questionnaire, I confirm that this program is for my own personal use, and will not be distributed to friends, family, other trainers/coaches or otherwise. This program and all its contents including bonus files, recipes and any information posted within the Sami Rose Fitness forum/website or during progress check-ins are owned by Sami Rose Fitness and no part of this program or its information can be reproduced, stored, transmitted or shared in any form, including email, photocopy, screen-shots, recording or otherwise. Sharing this program to a person/social media profile/site who has not purchased the guide or program is in violation of copyright, and if found to be in breach of said copyright, you may be pursued with legal action for this violation under the Copyright Act. By agreeing to this I acknowledge that I will abide by the confidentiality agreement both during my time as a client, and afterwards/ongoing. I also acknowledge the risks of online personal training – including but not limited to : self-managing injury risk prevention, correct form inclusive of warm up routines, following instruction, and seeking assistance where required (via video form checks through Sami Rose, or seeking help from a face to face trainer). I understand that Sami Rose Fitness cannot be responsible if I become injured due to incorrect form/weight selection, and should I have any concerns about the safe/correct execution of any movement I will request examples from Sami Rose, and send video form checks to ensure I am completing exercises safely and correctly at all times.

Please feel free to add as much detail as you can, so I can get to know your needs as best as possible!

Client Details

General health/fitness levels

Do you suffer from, or have been previously diagnosed with:

*All injuries/illnesses/conditions MUST be cleared with your GP/Doctor prior to commencing this program

SELF ASSESSMENT

Nutrition Information

Fitness Information

Are you experienced in the following lifts?
If so, please list approx weight used for 6-10 reps:

Your Health + Fitness Goals

Training Availability

Desired/Preferred Training Styles to be included

Please sign here

Your form has been submitted

CONTACT SAMI

QUICK LINKS

Please feel free to add as much detail as you can, so I can get to know your needs as best as possible!

Client Details

General health/fitness levels

Do you suffer from, or have been previously diagnosed with:

*All injuries/illnesses/conditions MUST be cleared with your GP/Doctor prior to commencing this program

SELF ASSESSMENT

Nutrition Information

Fitness Information

Are you experienced in the following lifts?If so, please list approx weight used for 6-10 reps:

Your Health + Fitness Goals

Training Availability

Desired/Preferred Training Styles to be included

Please sign here

Your form has been submitted

Login

Are you experienced in the following lifts?
If so, please list approx weight used for 6-10 reps: