CONQR In-Person Training Client Assessment

Full Name*

First NameLast Name

Age*

Gender*

MaleFemaleOther

E-mail*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What are your top 3 priorities in life right now?

Ex. My health, my family, and my clients

If a genie specializing in health/fitness/body transformations could grant you 3 wishes, what would they be?*

Its a fitness genie so it can't give you a million dollars

Did you ever play any sports? (Organized or Recreational)

YesNo

If yes, which sport(s) and when?

What are your top 3 favorite junk foods?*

What are your top 3 favorite healthy foods?*

Have you had any injuries, surgeries, or limitations that restrict you in any way?*

What are your 3 month fitness goals?*

When did you last feel happy and content with your body and energy levels?*

What drove you to reach out to me? *

Why do you think I can help you?*

What do you think I can help you achieve?*

How committed are you to achieving your health & fitness goals?*

	1	2	3	4	5

1 is Netflix & Twinkies all day!, 5 is I'll have broccoli & planks for lunch.

Are you willing to commit to training 2-4 times per week (depending on your goals) to get to where you want to be?*

YesNo

Is there any other family member or person who has a say in your decision to hire a coach or stick to a fitness program?*

YesNo