POWER HOUR CALL
Please fill this out in preparation for our call - 60 minutes goes quick! So I want to be sure I know as much about your goals for this call as I can. Please provide as much information as you feel comfortable sharing at this point. We will have the opportunity to go much more in detail about all of this on our call!
Name
*
First Name
Last Name
Email
*
example@example.com
IG Handle
Phone Number
*
Gender
*
Please Select
Female
Male
Genderqueer/ Non-Binary
Prefer not to say
Gender Pronouns
*
ex. he/his she/hers they/them, or any other pronoun, combination or variation you use.
Age
*
Height (inches)
*
Weight (lbs)
*
What do you do for work?
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Do you have any medical conditions or take medication that would interfere or affect your health journey? If so, please include any medications or treatments you are currently taking.
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What are your goals in this health & wellness journey? (Click all that apply)
Lifestyle changes
Healthy Habits
Better understanding of nutrition
Confidence around food choices
Weight loss/Fat loss
Increase Lean Mass
What are your specific goals as related to your health & fitness?
FITNESS
Current Activity Level
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Sedentary (limited activity)
Lightly active (light exercise less than 2x week)
Moderately active (moderate exercise most days of the week)
Very active (hard exercise 4-5 days of the week)
Extremely active (strenuous exercise more than 3x week)
Approximately how many hours do you sit during the day?
How often do you prioritize going for a walk?
0-1 time per week
2-3 times per week
4-5 times per week
6-7 times per week
On average, how many steps do you usually hit per day (if you have a tracker)
0-3,999
3,000-5,000
5,000-7,000
7,000-9,000
9,000-11,000
11,000+
What type of exercise do you currently take part in?
Bootcamp style classes (Orange Theory, Burn, F45, other group training classes, etc)
Strength Training
Crossfit
Spin/Biking
Running
Other
Please elaborate on your training schedule/routine (what it REALLY is....not what you want it to be, or what it used to be, or what you plan for it to be)
What do you ENJOY about your workout routine?
What is a barrier or roadblock to your workout routine?
NUTRITION
What is your biggest nutritional challenge? (click all that apply
Don't like to cook / don't know how
No idea what I'm supposed to eat
Lots of social engagements
No time to plan/prep meals
My portions are too big
I get too busy and forget to eat
Snacking
Night-time bingeing
Emotional/Stress eating
Other
Do you have any dietary restrictions or special dietary needs?
What types of food do you enjoy?
Please describe briefly what your current nutrition looks like (REALLY looks like, not what you think I want to hear...brutal honesty here)
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What about your nutrition do you feel confident about?
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What are the struggles you are facing with your current nutrition
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Past Diet History - what have you tried, what worked, what didn't.
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Have you ever been diagnosed with or struggled with an undiagnosed eating disorder?
*
Do you currently:
Meal Prep
Meal Plan
Neither - I plan as I go
What does your meal prep look like?
How many servings of veggies per day?
0-1
2-3
4-5
5+
What do your snacks usually look like?
How often do you drink alcohol
Never
0-1 times per week
1-2 times per week
3+ times per week
How often do you dine-out? Order Take-Out?
Never
0-1 times per week
1-2 times per week
3+ times per week
Have you ever tracked your macros before?
*
Please Select
YES
NO
What is your current caloric intake for a normal day (if you know)
LIFESTYLE
What are the things in your life that bring you happiness, relaxation - that fill your cup.
If you look into the future, 6 months, a year, 2 years, 5 years down the line - how do you want to feel? Where do you want to be? What do you hope to see in yourself?
Do you have a support system? Someone (or a group of people) that you feel support you in your health & fitness goals? Who provides this support? How do you feel supported by them?
THIS CALL
What do you hope to gain out of this One Time Fitness/Nutrition Consult Call
Do you have any specific questions you would like to address?
Submit
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