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A Self-Leadership and Adventure Experience
An EPIC ™ Global Delivery
Athlete Performance Coaching Questionnaire
Published
9 September 2024
1
Personal Details
2
Health & Exercise
3
Medical
4
Eat & drink & do
5
Goals, challenges & areas for growth
6
Additional information
Personal Details
Hidden
Trainer
Nam
Robbo
Hidden
Type
Executive
Athlete
Client Name
(Required)
First
Last
Occupation
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Primary Contact Number
(Required)
Email Address
(Required)
How did you hear about
Robbo
?
(Required)
Smoking
Do you currently smoke?
(Required)
I have never smoked
I quit smoking
Yes
When did you quit smoking?
(Required)
Number of cigarettes per day?
(Required)
Drink alcohol
How often do you drink alcohol?
(Required)
I don’t drink alcohol
Daily
Weekends
Rarely
Socially
How many per day/night?
(Required)
Unhealthy habits (strictly confidential)
Are there any unhealthy habits that could be impacting your wellbeing or performance? Tick below if you would like to discuss &/or understand more about the effects of continuing this habit.
(Required)
Alcohol
Drugs
Gambling
Other
No
Caffeine
Do you drink caffeinated beverages (i.e. coffee, tea, energy drinks)?
(Required)
I don’t have caffeine
Yes, I have tea / coffee
Yes, I have energy drinks
Cups / Shots per day?
(Required)
Sugar(s) per cup?
(Required)
Energy drink(s) per day?
(Required)
What time do you drink your last caffeinated beverage?
(Required)
Sleep Patterns
How many hours of sleep do you get per night on average?
(Required)
Less than 4 hours
4 to 6 hours
7 to 8 hours
8 to 10 hours
What time do you normally go to sleep?
(Required)
What time do you normally wake up / get up?
(Required)
Do you wake up during the night?
(Required)
Yes
No
Sometimes
If Yes, how many times?
(Required)
At what time/s approximately?
(Required)
Can you get back to sleep ok?
(Required)
Do you take sleeping tablets/natural substances for sleep?
(Required)
Yes
No
Sometimes
If Yes, what do you take (inc' brand name), how much & for approximately how long?
(Required)
Do you have a sleep routine?
(Required)
Yes
No
Sometimes
Details of Sleep Routine:
(Required)
Biological Markers
VO2 Max
Tested?
I haven’t been tested
What is your V02 max score (e.g 45ml/kg)?
(Required)
Date of Testing
(Required)
MM slash DD slash YYYY
A person’s VO2 max score measures the maximum amount of oxygen their body can use during intense exercise. It’s like a fitness gauge showing how well your heart, lungs, and muscles work together. Knowing your VO2 max helps track your fitness level, improve performance, and tailor workouts to get better results. It is the overarching factor of how much energy you are able to use.
HRV – Heart Rate Variability
Know HRV?
I don’t know my average HRV
Do you know your average HRV score whilst you sleep (e.g. 45ms)?
(Required)
Heart rate variability (HRV) measures the time differences between heartbeats. A high HRV indicates good heart health and adaptability to stress. Improving your HRV boosts daily (& athletic) performance by helping your body recover faster and manage stress better, leading to better overall well-being and resilience.
Blood Tests
Can you provide any recent blood tests that cover your overall level of health (no older than 3-4 months)?
(Required)
Yes
No
Please bring them along to the first consultation or email prior if the first session is virtual.
Body Scans
Can you provide a recent body scan that provides data on your fat %, lean muscle mass % etc (no older than 1-3 months)?
(Required)
Yes
No
Please bring them along to the first consultation or email prior if the first session is virtual.
Medical History
Please tick any of the conditions or symptoms you have or had a history of:
Thyroid
Hypo
Hyper
Date Thyroid removed:
Cancer Type
Date organ removed?
Chemotherapy:
Natural Therapies:
For Male
Prostrate problems
Date organ removed?
For Female
Pregnant
Bleeding problems
Endometriosis
Polycystic Ovaries
Date organ removed?
Medication
Do you take any medication on a regular basis either over-the-counter or prescribed by a physician (with the exception of birth control and health supplements)?
(Required)
Medical Questionnaire
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.
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?
(Required)
Yes
No
Description
(Required)
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?
(Required)
Yes
No
Description
(Required)
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?
(Required)
Yes
No
Description
(Required)
Do you have a history of tumour, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, or persistent sinus infection?
(Required)
Yes
No
Description
(Required)
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?
(Required)
Yes
No
Description
(Required)
If you have diabetes, Type1 or Type 2, have you had any trouble controlling your blood glucose in the last 3 months?
(Required)
Yes
No
Description
(Required)
Do you have any diagnosed muscle, joint or bone pain or problems that coud be made worse by doing physical exercise?
(Required)
Yes
No
Description
(Required)
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
(Required)
Yes
No
Description
(Required)
What I eat & drink & do
In the section 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
Robbo
can assist you.
Please then ALSO 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.
To continue you must add at least 3 entries.
Choose a day that replicates the way you eat & train ‘most’ days. Thank You.
Nutrition, Hydration, Supplementation
Time of Day
Physical Activity
Time of Day
Upon Rising
Time
Activity Details
Time
Breakfast
Time
Activity Details
Time
Snack (AM)
Time
Activity Details
Time
Lunch
Time
Activity Details
Time
Snack (PM)
Time
Activity Details
Time
Dinner
Time
Activity Details
Time
After Dinner
Time
Activity Details
Time
Other Notes:
Your goals, challenges & areas for personal growth
Please take a moment to tell
Robbo
what challenges and/or goals you would like assistance with. Thank You!
A Snapshot
If you’re unsure of any answers below, please write “to be discussed”.
What is your role? E.g. If you have a profession, what is your role? If you are not currently working in a profession what is your main role?
(Required)
What is your main sport? Are you an amateur / semi pro / pro / other?
(Required)
What personal strengths do you have that you believe will help you succeed in your role/s?
(Required)
What/Who encourages you and inspires you?
(Required)
When you think about the future, what are some of the experiences or things you would like to have in it?
(Required)
What contributes to you feeling like your most successful and fulfilled self?
(Required)
What are 3 of your biggest distractions that take you away from being productive, successful & feeling fulfilled?
(Required)
What are 3 of your biggest distractions that take you away from being focused, successful & feeling fulfilled?
(Required)
What are you most proud of in your life?
(Required)
What are you most proud of a) in your life and b) in your sport?
(Required)
Where do you feel most alive outside of your sporting performance space?
(Required)
Clarity
If you’re unsure of any answers below, please write “to be discussed”.
What are the top 3 performance &/or well-being (mind/body) goals you would like to achieve this year?
(Required)
What are the top 3 sporting &/or personal growth (mind/body) goals you would like to achieve this year?
(Required)
What is/has been standing in your way of achieving these goals?
(Required)
What do you feel this is costing you, in terms of lost time, relationships, money, other?
(Required)
What is your definition of success with these goals, how will you know when you’ve achieved them?
(Required)
What are some future obstacles that could get in your way?
(Required)
What are 1-3 things that you would like to become extraordinary at?
(Required)
Can you define your most important needs from
Robbo
?
(Required)
Energy
If you’re unsure of any answers below, please write “to be discussed”.
What are your 3 biggest stressors that use up most of your energy?
(Required)
What do you do to minimise the effects of stress (good/bad stress) or recover from your work day? Any routines?
(Required)
What do you do to minimise the effects of stress (good/bad stress) or recover from training, comps etc? Any routines?
(Required)
What provides you with the most amount of ‘consistent’ energy i.e not a hit of caffeine?
(Required)
Well-being Self Assessment | SCALE 1 = LOW through to 10 = HIGH
In the spaces below, please fill in your scores 1-10 for each. Briefly explain your score, thank you.
MENTAL: You realise your potential, can effectively deal with stress & contribute to your family, friends & community.
0
1
2
3
4
5
6
7
8
9
10
Please enter a number from
0
to
10
.
MENTAL: Explanation
(Required)
PHYSICAL: Having great energy, fitness, mobility, & the capacity to engage in daily tasks/exercise.
0
1
2
3
4
5
6
7
8
9
10
Please enter a number from
0
to
10
.
PHYSICAL: Explanation
(Required)
EMOTIONAL: Ability to produce positive emotions, feelings, thoughts & moods &/or adapt to stress
0
1
2
3
4
5
6
7
8
9
10
Please enter a number from
0
to
10
.
EMOTIONAL: Explanation
(Required)
Additional information you wish to share
Additional Information
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.
PARTICIPANT’S SIGNATURE (type name)
(Required)
Date
(Required)
DD slash MM slash YYYY
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An EPIC ™ Global Delivery
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