Let's Get FIT!
This form will help us create a program designed to help you reach your goals while focusing on your specific health & fitness needs.
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Email
*
example@example.com
Briefly tell me about your exercise history throughout your life
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Tell me about your health & fitness habits in the LAST 90 days
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Where would you like to see yourself in the NEXT 90 days (be as specific as possible)
How can I best help you stay accountable and reach your goals?
What level of coaching are you looking for?
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Online Workout Plan
Online Nutrition Plan
Online Workout & Nutrition Plan
Virtual Training
In-Person Training
How soon would you like to start?
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
My BEST Self
On a scale from 1 - 5 rate the MOST important (1) to least important (5)
Feel better (energy & mood)
Weight loss visible on the scale
Clothes fitting loose
Visible muscle tone
Feeling STRONGER
Workouts!
What type of equipment do you have access to?
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I'm a member of a gym
There's a gym in my building
Dumbells
Exercise bands
Cardio: Treadmill/Bike
Jump rope
Other
How many times per week will you be able to workout?
2 times per week
3 times per week
4 or more times per week
How much time will you have availabe for each workout?
Nutrition
Let's create healthy eating habits!
What is your food intake like on most days? Be as descriptive as possible.
Please list any food allergies or restrictions
List any medications or supplements that you are currently taking
Last but not least...
Current weight
Goal Weight
Height (in inches)
Age
Submit
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