ATHLETE INFORMATION

First Name

Last Name

Age

Phone

Select an option

Male

Female

Other

Prefer not to answer

Time Zone

Mailing Address

Are you active military or a student?

Yes

Are you currently working with another coach or trainer?

Yes

Your Height (feet/inches/meters)

Current body weight

Weight History (Describe)

What is your daily, non-exercise activity level?

What are your short-term goals? What would you like to discuss during consultation?

What are your long-term goals?

WEIGHT TRAINING

Please summarize your current weight training split/regimen.

How many sets do you generally perform per workout? If unknown, would you describe your training as low, medium, or high volume? What rep range(s) do you work in? How often do you train to failure or post failure?

NUTRITION

Describe your current nutrition intake, include total calories, carbs, protein and fats. If unknown, list your food intake (type and amount) for a typical day.

What are your current eating patterns on any given day? Please describe a typical breakfast, and dinner. Please describe typical snacks or between-meal tendencies. (Be specific by naming typical foods eaten, macronutrients, fruit/vegetables, restaurant food, etc.)

Do you have any food allergies or intolerances? Any additional information relevant to your nutritional status?

CARDIOVASCULAR TRAINING

What is your current cardio regimen? Include schedule, intensity and type

SUPPLEMENTATION

List all supplements you use, including their frequency and dose

MEDICAL HISTORY

Please list any medical diagnoses (e.g. Kidney disease, type II Diabetes, hypertension, PKU, etc.) – If none, type “N/A”. If present, are the conditions stable as determined by a qualified health care professional?

Please list any injuries or ongoing pain that currently inhibits your ability to train as desired.– If none, type “N/A”

Family history of medical diagnoses (Who? What? Example: Mother- Type II Diabetes)

Medication History (Past meds)

List all medications you currently take (insulin, birth control, TRT, HRT, etc.), including their frequency and dose

Menopause status (Females Only)

LIFESTYLE

Can you describe a typical or recent day in your life that would help us understand you?

Can you balance the time you spend focused on your food, your body weight and composition, and your nutrition plan progress with other aspects of your life such as your relationships, work, and personal development?

Please list three prominent stressors you have at this time

Has your weight or shape influenced how you think about (judge) yourself as a person?

Do you have any food or exercise rituals that concern you? If yes, please explain

During the past month, have you often been bothered by feeling down, depressed, or hopeless?

PLEASE UPLOAD THE FOLLOWING PHOTOS

Current photo displaying your physique (front pose).

Current photo displaying your physique (back pose).

If applicable, a photo of your military or public safety ID.

WAIVER

Matt Costa Fitness is not a licensed dietitian or nutritional specialist. All information you obtain will be directly from Matt Costa’s own experiences. It is of best interest for anyone looking to start a bodybuilding contest preparation/ fitness program to consult a physician before doing so; it would be wise to have blood work done, and a physical performed by a licensed physician.

Before submitting this application, please read and understand the following: You(customer) totally understand that you(customer) may injure yourself as a result of participation in a bodybuilding contest preparation/fitness program, and hereby release Matt Costa Fitness, (Website) and Matt Costa from any liability now or in the future for any injury, including, but not limited to heart attacks, death, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries and any other illness, soreness or injury however caused , occurring during or after my participation in the bodybuilding contest preparation/fitness program offered.

By submitting this application, you state that in consideration of your participation in Matt Costa Fitness (website) online personal training, you for yourself, your personal representatives, administrators, heirs and assigns, hereby holds harmless Matt Costa Fitness (website), and Matt Costa from any claims arising from your participation in online personal training.

By submitting this application, you agree that you have listed all current/past medications and diagnoses, and that you have spoken with your doctor and been cleared to participate in your planned activities

By submitting this application, you agree that you have are being seen by a physician for your current medical diagnoses/medication regiment, and if for any reason you stop seeing your current physician for the above conditions/medications you will inform Matt Costa Fitness.

By submitting this application, you affirm that you have read, have been honest with Matt Costa Fitness (website), and Matt Costa and also fully understand the above information. You have been given the opportunity to present questions in all related matters. You agree that if at anytime the status of your condition changes you will inform Matt Costa Fitness

I agree to the terms of this waiver.

Thanks for submitting!

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