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Full Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
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Sex?
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Male
Female
I'd rather not say
Birthday
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Month
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Day
Year
Height
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Weight
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pounds
Do you have (or have you ever been diagnosed with) any of the following conditions?
Insulin resistance
Diabetes (type 1 or 2)
Menopause/perimenopause
PCOS
Hypothyroidism
Hyperthyroidism
Anemia
Post bariatric surgery
Other
Please describe your primary goal:
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Please describe your past dieting history, what programs have you participated in? What success have you had? What have you not liked?
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Are you following a specific nutrition diet or exercise routine currently?
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Yes
No
If you answered yes above, please explain.
Have you ever tracked calories/macros before?
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Yes
No
Select your current activity level
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Not active (less than 5,000 steps/day, no structured exercise)
Minimal activity (less than 5,000 steps/day, 1-2 days of exercise)
Moderate activity (5-7,000 steps/day, 2-3 days of exercise)
High activity (7-10,000 steps/day, 3-4 days of exercise)
Extremely high activity (>10,000 steps/day, 5+ days of exercise)
What type of exercise do you like?
Weightlifting
Cardio (running, elliptical, stairmaster, biking, etc.)
Group fitness classes
Pilates/yoga
Crossfit
Other
If you are currently exercising, please describe your current routine
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Do you have any injuries that prevent you from exercising? If yes, please explain. If no, please leave blank.
How many hours of sleep do you average per night?
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What is your motivation for making a change and pursuing coaching?
What are you looking for in a coach? Have you worked with a coach before and how was that experience?
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What is it about Tayla's coaching philosophy towards coaching and nutrition that encouraged you to inquire about her services?
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What is the biggest challenge you feel in pursuing a healthy lifestyle?
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What type of coaching are you interested in?
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Nutrition coaching only
Nutrition coaching with workout programming
The cost for weekly 1:1 coaching and workout programming will range between $400-$450 per month with a 3 month upfront commitment (discounts for paying in full). Is this within your budget? Please note: if this is not in your budget, please consider applying later when it is.
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Yes this is within my budget
Are you fully committed to put in the time and effort required to make changes to your lifestyle? (These services are intended for individuals who are willing to put in the consistent work in order to change their habits and behavior.)
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Yes
No
How did you hear about Tayla:
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Appointment date & time:
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SUBMIT
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