Health & Fitness Program Questionnaire

Please Complete This Questionnaire

We are very excited to provide you with tools which will help you develop skills and motivation to fulfill your most sought out health and fitness goals.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Age *
Weight *
Height *
Which areas of health have the most fulfillment in your life?

Social Intellectual Occupational Physical Emotional Environmental Financial Spiritual
Which areas of health lack fulfillment in your life?

Social Intellectual Occupational Physical Emotional Environmental Financial Spiritual
Which areas of health would you like to have the most fulfillment in?

Social Intellectual Occupational Physical Emotional Environmental Financial Spiritual
What is your goal? Lose 20lbs? Gain 20lbs of muscle? Overcome depression and anxiety? Be specific. It doesn't just have to be a physical goal. *
What health and fitness strategies have you tried in the past and why have they not worked for you? What's stopping you from hitting your goal? *
Do you have any injuries, medical conditions or limitations we need to be aware of? *
On a scale of 1-10... 1 being I'm satisfied where I am and 10 being I'll do anything to reach my goal. What number are you? *
Are you willing to invest financially to reach your goals, if we find a plan that fits within your budget? (Be ready to move forward on the call if you and I decide you're a good fit for this program) *
Is focusing on your health a right now thing for you? Why now? *
What foods do you typically have for breakfast?
What foods do you typically have for lunch?
What foods do you typically have for dinner?
How many days per week would you like to workout?
Are you happy?
Please write three things you are happy about and three things you are unhappy about.
Should be Empty:

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Please Complete This Questionnaire