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Performance Coaching Questionnaire

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Performance Coaching Questionnaire

Performance Coaching Questionnaire

PERSONAL DETAILS

HEALTH & EXERCISE SCREENING

SMOKING

Do you currently smoke?

DRINK ALCOHOL

How often do you drink alcohol?

CAFFEINE

Do you drink caffeinated beverages (i.e. coffee, tea, energy drinks)?

SLEEP PATTERNS

How many hours of sleep do you get per night on average?
Do you wake up during the night?
Do you take sleeping tablets/natural substances for sleep?
Do you have a sleep routine?

MEDICAL HISTORY

Please tick any of the conditions or symptoms you have or had a history of:

Thyroid
For Male
For Female

MEDICATION

Performance Coaching may involve demanding physical activity and can be strenuous and you need to be in good health to participate. The purpose of the Medical Questionnaire is to find out if you should be examined by a physician before participating in Performance Coaching Activities. A positive response means that there is a preexisting condition that may affect your health & safety when training and you may need to seek the advice of a physician (we will advise).

Please answer the following questions on your past and present medical history by ticking YES or NO. If you are not sure, answer YES. Please provide further information on your answer in the spaces provided below each question.

MEDICAL QUESTIONNAIRE

Do you have a history of seizure disorder, stroke, brain surgery, black out, severe migraine headaches, vertigo or dizzy episodes, significant head injury or aneurysm of the brain’s blood vessels?
Do you have a history of heart attack, heart surgery, irregular heart beat, angina/heat pain, heart disease, uncontrolled elevated blood pressure (hypertension), heart murmur, known patent foramen ovale (PFO), high cholesterol, anaemia or unusual shortness of breath or chest pain during exertion?
Do you have a history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, severe damage to lung tissue, emphysema, pneumonia or any lung problem which interferes with your ability to breathe?
Do you have a history of tumour, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, or persistent sinus infection?
Have you had a history of asthma or asthma attacks in the last 12 months requiring medical attention? Any condition requiring medication and/or use of an inhaler for control of wheezing?
If you have diabetes, Type1 or Type 2, have you had any trouble controlling your blood glucose in the last 3 months?
Do you have any diagnosed muscle, joint or bone pain or problems that coud be made worse by doing physical exercise?
Do you have any other medical condition(S) that may make it dangerous for you to participate in physical activity/ exercise?

IF YOU ANSWERED ‘YES’ To any of the 10 questions, we may ask you to seek guidance from your GP or appropriate allied health professional prior to undertaking any physical components of the Performance Coaching Programs.
IF YOU ANSWERED ‘NO’ To all of the 10 questions, and have no other concerns about your health, you may proceed to undertake the activities within the Performance Coaching Program at your own risk.

WHAT I EAT & DRINK & DO

On the LEFT below, please record below what you eat & drink (including supplements) in a normal day (& the time). Please be as descriptive as possible i.e. instead of just writing ‘chicken and vegetables’ you would include the types of vegetables, instead of ‘pasta & sauce’ you would include type of pasta & what sauces, dressings etc. The more information you provide, the better Nam can assist you.

On the RIGHT below, please record what fitness activities you do in a normal day (& the time). Be informative i.e. instead of just writing ‘jogging’, you would include how far/long and the intensity etc.

Choose a day that replicates the way you eat & train ‘most’ days. Thank You.

Nutrition, Hydration, Supplementation

Time

Physical Activity

YOUR GOALS, CHALLENGES, & AREAS FOR PERSONAL GROWTH

Please take a moment to tell Nam what challenges and/or goals you would like assistance with.  Thank You!

A SNAPSHOT

CLARITY

ENERGY

WELL-BEING SELF ASSESSMENT | SCALE 1 = LOW though to 10 = HIGH

In the spaces below, please fill in your scores 1-10 for each. Briefly explain your score, thank you.

ADDITIONAL INFORMATION YOU WISH TO SHARE?

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.

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    With over 28 years experience in the health, fitness & wellbeing industries worldwide, Nam specialises in emotional & physiological intelligence & peak performance. He continually explores the achievement of success in high pressure situations. He is a life, health & peak performance coach, strength & conditioning coach, powerful corporate trainer, and a hugely popular keynote speaker.

    Nam is sought after by elite athletes, teams & is the well-kept secret of many ‘top 1 percenters’ in the business world. His gift of simplifying the complicated science behind brain & body performance, & delivering it in life-changing, digestible sessions, creates proven successes.

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