Go Well Beyond
make it a lifestyle
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Occupation
*
Sex
*
Please Select
Female
Male
Age
*
BIRTH Date
*
-
Month
-
Day
Year
Date
In a few sentences, tell me a bit about you - hobbies, family, fun facts. This helps me get to know you personally!
Health history (check all that apply):
*
History of heart problems, chest pain, or stroke
Current chronic illness or condition
Previous chronic illness or condition
Elevated blood pressure currently
Advice from physician to not exercise currently
Recent surgery (last 12 months)
Currently pregnant
Pregnant within the last 3 months
Currently breastfeeding
History of breathing or lung problems
Breathing or lung problems currently
Past smoker
Current smoker
Muscle, joint, or back disorder, or any previous injury still affecting you
Type 1 Diabetes
Type 2 Diabetes currently
Elevated blood cholesterol currently
History of heart problems in immediate family
Hernia, or any condition that my be aggravated by lifting weights or other physical activity.
Weight loss surgery
NONE
Other
Please provide additional detail for ALL items checked above. or any additional medical conditions/physical limitations:
What are your general health, nutrition & fitness goals? (mark all that apply)
*
Fat loss
Gain weight
Be fit/strong/athletic
Reduce bloating
Improve metabolism
Create strong healthy habits, routines, & rituals
Live my healthiest life (realistically & sustainably)
Eat intuitively/stop using MyFitnessPal (food tracking)
Fuel for sports/athletics
Improve nutrition choices/quality/habits
Improve nutrition consistency
Improve general health
Manage/improve health conditions (diabetes, blood pressure, cholesterol, etc.)
None of the above
Other
Tell me more about your goals. Tell me exactly what you want to accomplish & create. Share all details, get specific.
*
If you selected 'manage/improve health conditions', please share details.
Types of exercise you enjoy (mark all that apply)
*
Walking
Running
Dancing
Swimming
Cycling
Sports
Weight lifting
Circuit/interval training
Functional fitness
Conditioning (higher intensity)
Pilates/Barre
Yoga
Boxing
Martial Arts
Other
What type of support are you interested in? *Mark all that apply*
*
Personalized plan/protocol (nutrition and/or exercise)
Messenger support, coaching, guidance, accountability, & motivation
App workouts to complete on your own
In person personal training (for LOCAL residents only)
Anything else you'd like to share/questions you have?
*
How did you hear about Well Beyond
*
Please Select
Email
Social Media
Referral
Previous client
Coach Christine
Fit 60
Other
Submit
Should be Empty: