Fuse Health and Fitness

New Client Form
*I understand that all information I entered in this form will be considered strictly confidential. The data gathered from this form will only be used by the FUSE team to better help serve my needs and will NOT be shared with anyone else.*
Name*

First NameLast Name
Age*
Physical Sex*

MaleFemalePrefer not to sayOther
Email*
example@example.com
Mailing Address (so we can send you some goodies!)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation/Job
Do you have any health conditions that you would like to share?*

YesNo
If yes, then please share them below:
Do you currently take any medication(s)?*

YesNo
If yes, please indicate medications name and purpose below.
What are your personal goals (fitness, nutrition, lifestyle, competition, etc.)*
What changes would you like to see in your life right now?*
What is your "Why"? What motivates you to want to see change?*
What number would best represent your typical stress levels.*

1

2

3

4

5

6

7

8

9

10

1 is Not Stressed , 10 is Extremely Stressed
Typical water intake/ day (fl. oz)*
What are 3 foods/beverages you CAN'T LIVE WITHOUT?*
What are 3 foods/beverages you WONT EVER BE CONSUMING?*
Any food allergies you are aware of? If so, please list them here.
What are 3 strengths you have that will help you achieve your goals?*
What are 3 weaknesses that could hinder your reaching your goals?*
What metrics would you like to track (check all that apply)*

SleepWater IntakeStepsResting Heart RateBody measurementsWeight
What exercise equipment do you have access to (check all that apply). For our program, you will require access to some gym equipment.*

Free weightsBarbell and platesCardio equipmentI have a home gymI have a gym membership
Which Fuse Track are you wanting to join?

Fuse BeginnerFuse EverydayFuse Athlete/Competitor
Which of our Fuse Health and Fitness Coaching Options are you most interested in?*

4 Month FUSE All in One Package: Fitness, Nutrition, and Lifestyle coaching! (Base Value - $300/month)6 Month FUSE All in One Package: Fitness, Nutrition, and Lifestyle coaching! (BETTER Value - $250/month)12 Month FUSE All in One Package: Fitness, Nutrition, and Lifestyle coaching! (BEST VALUE!! - $200/month)
How would you like to do your monthly check-ins?*

Video CallPhone CallEmail
How did you find out about our services?*

FacebookSearch EngineInstagramYouTube VideoOther
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New Client Form