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In order for me to have a better understanding of what type of program you are
looking for, please complete the following 5-minute 50 Point Health
Questionnaire below. After you submit the form I will review your application
and will contact you about the Phone Coaching Call.
Phone Coaching Health Questionnaire
Name:

Phone # (day/evening):

Email Address:

Birthdate:

Male or Female:

Height

Weight:

Optimal Time to Exercise:

Occupation:

How did you hear about us:
Which program are you most interested in: (Hold down the control key to select
multiple categories.)
Please check the box to the left of the condition if you have any of the following:  
Heart Disease

Pulmonary Disease

Metabolic Disease

Family History of Heart Disease

High Blood Pressure

High Cholesterol

Smoking

Sedentary Lifestyle

Chest Pain

Dizziness

Shortness of Breath

Irregular/Accelerated Heart Rate

Osteoporosis
Are you over 69 and not used to being active?

Is your physician prescribing medication for a blood pressure or heart condition?

Has a physician ever told you that you have a bone or joint problem that will
worsen with exercise?
Do you know of any reason why you should not participate in physical activity?
How many days a week are you currently working out? (0-7x)
How long are your typical workouts? (ie. 30 minutes weights/ 30 minutes cardio, etc)
How many days a week would you realistically like to see yourself working out?
Describe Your Ideal Fitness Coach (personality, special interests, etc.)
What Are Your Fitness Goals (weight loss, definition, energy gain, etc.)
What are your interests (running, biking, swimming, etc)
Why should you be chosen as a candidate to do phone coaching?
Congratulations! If you’ve made it this far you are well on your way to achieving
any goals that you have set for yourself. Your determination and the correct
exercise program will keep you motivated and attaining your goals!
Arthritis/ Joint Pain

Back Pain/Spine Disorder

Musculoskeletal Pain/ Injury

Hernia

Surgery

Other

Hypoglycemia

G.I. Disorder

High Triglycerides

Cancer

Pre/Postnatal

Anemia

Food Allergies
You've taken the 1st step toward achieving all of your health & fitness goals!
Please fill in as much information as possible to allow Stephen to have the best
possible picture of how he can help you achieve your goals.
Yes Steve! I want to be one of the new clients you accept this month for to speak with you
personally. I understand that the application process does not ensure that I will be selected, but I am serious
about transforming my body and my health! I want to be your next success story!
Please fill out Stephen Cabral's Phone Coaching application below:
(please be as detailed as possible)
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Stephen Cabral
Stephen Cabral
Online Fit Life Coaching