Leia Nicole Fitness

Submission Date*

Date

Name*

First NameLast Name

Birth Date*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Instagram Handle (if applicable)*

Age/Height/Weight*

How many calories are you currently eating a day? Please include also how many grams of carbs/fats/protein you’re getting. If you are not sure, are you willing to track your food in My Fitness Pal for a week before we start a program?*

What TYPES of foods do you usually eat every day (what does a typical day look like)*

Have you been gaining, maintaining or losing weight over the last 3-6 months?*

What have you been doing for cardio exercise the past 6 months? Please be specific(how many days a week, how long are your sessions, are you doing HIIT or walking or running, etc)*

What supplements are you currently taking?*

Are you taking any medications or under the care of a physician for anything? If so, please describe:*

What areas of your body/trouble spots do you want to focus on?*

What do you like/enjoy about exercise, and what do you dislike?*

How active are you outside of the gym? (are you highly active, are you in any sports, do you have a sedentary job, etc) What do you do for a living?*

When was the last time you stuck to a diet? Did you see results? If no, why do you think that is?*

Have you ever done a fitness program before? (like a weekly class, go to the gym, see a trainer, or use workout DVDs like P90x, etc) if so, what did you do and for how long?*

Have you ever seen results from a workout program? If no, why do you think you didn’t see or maintain those results?*

What do you feel you struggle with when it comes to diet and exercise? (can't find the motivation, it's too hard, don't know where to start, struggle with emotional eating/forgetting to eat, etc)*

Do you ever have any chest pain, trouble breathing, knee pain, joint or muscle pain?*

What are your short term goals?*

What are your long term goals?*

Do you have a history of eating disorders or restrictive eating?*

How would you rate your overall digestion? Please list any current or past issues.*

Do you understand that everyone's body is different, and it may take some time and patience to start seeing results?*

Are you usually hungry between meals?*

How many alcoholic drinks do you have a week? Do you smoke?*

How comfortable do you feel performing strength training exercises with weights?(be specific with how much experience you have, how heavy you have lifted in the past, etc)*

How comfortable do you feel with HIIT (high intensity interval training) and cardio type exercises?*

Please list and describe any injuries or things I need to be aware of when I am designing your program.*

Would you like workouts for at home, at the gym or both? If at home, please also list what equipment you have available to you.*

Please list how many days you will REALISTICALLY workout a week (not how many days you wish you could workout) and the amount of time you can dedicate to each session.*

What is your reason, your WHY for wanting to start a fitness program? What kind of results would you like to see? (example: fat loss, tighten and tone, become healthier overall, learn how to maintain a healthy weight, increase confidence and motivation, build lean muscle, have more energy, establish good habits, etc)*

Are you ready to commit to keeping a food log, making lifestyle changes, and being consistent with checking in with your coach weekly? Rate your readiness on a scale of 1-10, with 10 being “HECK YEAH I AM 100% COMMITTED, FAILURE IS NOT AN OPTION” and 1 being “I AM PROBABLY NOT READY AT ALL AND NOT EVEN SURE WHY I AM DOING THIS”.*

What is your timeline for achieving your goal? (12 weeks, 16 weeks, 24 weeks, 32 weeks, 40 weeks, 1 year)*

What are your expectations of ME as your personal trainer and coach?*

Which days of the week are the best days for you to workout? And what time... Morning, afternoons or evenings?*

Please upload a couple photos of yourself so that I can get an idea of your body type

File Upload

Is there anything else you would like to tell me?*

Today's Date:*

Date

Signature*

Sign with finger or mouse