ASSESMENT FORM

This is an evaluation form, it is designed to assess the symptoms that may relate to Nutritional imbalance & an unhealthy lifestyle. Its purpose is to educate and inform the individual. It is not designed to diagnose disease, if you suspect you have a problem that requires the attention of a medical practitioner, please see your Doctor for medical care. Ryan Rosier is not a doctor or registered dietitian.

The contents/info you receive should not be taken as medical advice. By participating in RCT’s approach to nutrition, fitness and overall wellness, you are agreeing to accept full responsibility for your actions. All contents/info included or exchanged between RCT and the Client are that of Ryan Rosier and not to be copied, sold, or redistributed. As with any exercise program, you assume certain risks to your health and safety, any form of exercise can cause injuries if the exercises are performed incorrectly, and at New Life Style there is no exception.

It is possible that you will not lose fat, gain muscle, or get ab definition with this program as fast as desired. It is also possible that you will gain fat, lose muscle, and lose ab definition. Your results may vary, and you may not get the same results when using this program due to differences in your individual exercise history, genetics, and personal motivation, please keep in mind that as we progress and understand your body and lifestyle, Ryan will be able to adjust more accurately to see results faster while still in a safe time frame.

ASSESMENT FORM

Full Names:

Date of Birth yyyy/mm/dd:

Age:

Email:

Contact Number:

If there is anything you don’t know. Type in:

"not sure" or

"still figuring it out"

Goal Weight:

Current Weight:

Relationship Status:

Tell me why you reached out now and not 3 months ago?

In your own words, what’s the main problem you want solved?

Who do you want to become through this coaching process?

What has this problem cost you in your daily life?

How would your life look if this problem disappeared?

Do you have Children, if so how many and age please:

What is your occupation:

What country & city are you from:

Do you like your occupation:

Yes

Sometimes

Can you walk around in the streets or to the park, beach in your area:

Yes

Sometimes

How much Travelling outside of your city or country is planned for the next 6-12months?

nothing

weekly

monthly

From 1 - 10, are you Happy with your life? Please tell me why (short paragraph):

What Gym’s will you be training at? please specify full name’s

If at home, what equipment do you have access too?

How many times a week can allocate towards physical fitness?

Which days of the week do you realistically see yourself training?

What approaches have you tried before? What worked? What failed?

When you think of your past inconsistencies, what usually gets in the way?

What kind of coaching style helps you stay accountable? i.e. Direct – Supportive – Structured – Autonomy – Tough love

Medical History

Do you have any underlying conditions?

If yes, are you manging it well and have a doctor assisting you?

Do you take any medication?

Have you been hospitalized recently? (last 12months) If yes, why?

Note: If you have answered yes to any of below questions, you should consult your physician or other appropriate health care provider before engaging in any exercise as you may need to use a facility with a medically qualified staff NOTE: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.

PARQ

Doctors name and contact details:

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

Is your doctor prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change inyour physical activity?

Yes

Do you feel pain in your chest when you do physical activity?

Yes

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

In the past month, have you had chest pain when you were not doing physical activity?

Yes

Do you know of any other reason why you should not do physical activity?

Yes

RSQ

I have been diagnosed with a heart condition Yes/No

Yes

I currently have a heart condition

Yes

I experience chest discomfort when exercising

Yes

I experience unreasonable breathlessness

Yes

I experience dizziness, fainting or blackouts

Yes

I am currently Diabetic

Yes

I have cystic fibrosis

Yes

I have asthma or any other lung illness

Yes

I get burning sensations in my legs when walking short distances

Yes

I have musculoskeletal problems that limit my physical activity

Yes

I take prescription medication

Yes

I am currently Pregnant

Yes

RFQ

I am a male, older than 45 years old

Yes

I am a female older than 55 years old, postmenopausal or have had a hysterectomy

Yes

I currently smoke or have quit within the last 6 months

Yes

I have been diagnosed with high blood pressure, or have been given prescription medication for hypertension

Yes

I am uncertain of my blood pressure

Yes

I have been diagnosed with high cholesterol, or been given treatment for hyper cholesterolemia

Yes

I am uncertain of my cholesterol levels

Yes

I have had a close blood relative have a heart attack (mother, sister under 65 years old, father or brother under 55 years old)

Yes

Text

I am currently not getting more than 30 minutes of physical activity 3 or more times per week

Yes

Blood Type & Testosterone

What is your blood type?

What is your Testosterone Level?

Nutrition

Give 2-3 options for Breakfast, Lunch & Dinner please.

The more I know, the better I can make your Nutrition Guide.

What is your ideal Breakfast?

What is your ideal Lunch?

What is your ideal Dinner?

Do you enjoy smoothies for breakfast?

Yes

Do you eat protein 3x a day?

Yes

Do you eat green veggies 2x a day?

Yes

Do you eat Fruits 2x a day?

Yes

What are your favourite foods?

What does a normal day of eating look like for you?

Rate your schedule: flexible, moderate, or tight.

Family History

Does anyone in your family have Diabetes

Sibling

Cousin

Parents

Other

Does anyone in your family have Cancer:

Sibling

Cousin

Parents

Other

Does anyone in your family have Mental Illness:

Sibling

Cousin

Parents

Other

Does anyone in your family have Heart issues:

Sibling

Cousin

Parents

Other

Have you ever been treated for a drug or alcohol problem?

Yes

If yes how long ago and do you feel stable now? Sorry if this question makes you feel uncomfortable

What support do you feel you need from me to succeed?

I want high-contact coaching with weekly check-ins, accountability, and regular adjustments.

I want moderate support with check-ins every two weeks and guidance as needed.

I prefer low-frequency support with a monthly check-in and strategic updates.

I am choosing this coaching process because?

I want expert guidance and structure; I need a proven system to follow so I can get results without guessing.

I want accountability and support; I know what to do, but I need consistency, direction, and someone to keep me on track.

I want a full transformation; I want to overhaul my training, nutrition, habits, and lifestyle with a coach who can guide me step-by-step.

I understand that small actions done consistently will produce better results than perfection.”

yes, I understand

I am willing to communicate honestly so we can build results together.

yes

Lastly, Please let me know if there is anything else you think I should know regarding this topic?

https://www.rosierct.com/wp-content/uploads/2025/08/ROSI3R-Coaching-Techniques-Ts-Cs.pdf

Please Confirm you have read the Terms & Conditions

I Accept the Terms & Conditions

Consent

RCT is focused on educating individuals on Health, Fitness & overall Wellness. Guiding Individuals to a better, safer, more focused way of living. Structured to their way of life.

Consultations at RCT do not include medical advice and are intended to compliment your doctor’s treatment.

Your physician can and should be advised of any information or recommendations in all sessions.
I hereby attest that I am here today and at any subsequent consultation/session, solely on my own personal behalf and/or on behalf of my immediate family to receive nutrition, fitness and lifestyle guidance, that I may choose to apply in my everyday life. I recognize that the services offered by Ryan Rosier & RCT do not involve medical diagnosis or treatments of any disease. I undertake full responsibility for my own wellbeing as it relates to my sessions.

Waiver of liability

Recognizing that participation in any physical activity includes the inherent possibility of both external and internal injury and acknowledging that in Ryan Rosier's capacity as my personal trainer/coach takes every precaution to prevent the above.

As I submit below I waive all legal claims against Ryan Rosier for any injury or damage that I might incur during or as a result of my participation in a training program designed by Ryan Rosier.

Cancellation policy

By submitting this form, I also understand and accept that the full appointment fee will be charged if any cancellations or rescheduling is not done 24 hours prior to the date of my appointment.

Social Media reputation:

By signing up, you grant me permission to capture videos and photos of your journey—from day one until you reach your goal.

This allows me to showcase real client transformations, build my reputation as a proven hybrid coach, and inspire others with tangible results.
Your progress story will motivate someone else to take the first step!

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