Strength To Endure Fitness Consultation Form:
Remember... With ME and YOU we together can Conquer the Yo-Yo Dieting Cycle!
Full Name
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First Name
Last Name
Phone Number
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Format: (000) 000-0000.
E-mail
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example@example.com
Age
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Gender
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Male
Female
Non Binary
Height
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Weight
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Select all that apply
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I want to loose weight
I want to gain lean muscle mass
I want to gain more energy
I want to live healthier and eat better
I want want to focus on fitness therapy
Are you familiar with using a food tracking system: Ex. MyFitnessPal, Carbon etc.?
Yes
No
Fitness Background (sports, current workout regimen)
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Goals:
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Injuries or Health Risks: (ie: high blood pressure)
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Favorite Foods by Category: *
Protein: Meat or Non - Meat Source (ie: Chicken, Salmon, or Veggie Burgers)*
Carbohydrate: (ie: Sweet Potato, Beans, Fires) Please be honest. No judgment!
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Fats: (ie: almonds)
*
Favorite Meal/Food/Restaurant: (ie: Pizza)* Please be honest. No judgment!
*
Do you know what triggers your food habits? Please explain in detail If are aware.*
Are you aware of your daily habits? List/explain 5 habits that you would like to work on to conquer the cycle of yo-yo dieting?
*
What is your mindset towards your goals? Do you believe you can Endure to conquer your goals?
*
Appointment: All Meetings will be virtual. Please be sure to look for a link sent to your email. First consultation is free.
Signature
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