First & Last name
Phone Number
 -
Area Code
Phone Number
Email:
Needed for your program
Instagram Handle:
Helps me get in contact with you
Gender:
Male
Female
Age:
Height:
Weight:
What’s your overall goal?
Lose weight
Gain weight
Increase general fitness
Gain strength/Tone up
What would you rate your level of fitness 1-10 (10 being very experienced)?
What’s your occupation?
What’s the activity level at your job?
None (seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Any physical activities you participate in outside the gym/work?
List any injuries/medical history you may have:
Are you experiencing any life stressors/motivation issues?
What do you struggle with the most when it comes to your fitness journey? What holds you back from achieving your goals?
Are you ready to physically, financially, and emotionally invest in yourself?💫
Is there anything else you'd like to tell me?
Any comments, feedback or suggestions are welcome!
What type of equipment do you have access to?
Ex: gym, bench, dumbbells, bands, etc.
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