Blond Myth Fitness & Nutrition Consultation Questionnaire
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
How did you hear about me?
Best day/time for a phone consultation
Gender
Male
Female
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
years
Height
in
Weight
Lbs
What do you do for a living?
Whats the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?
Rarely
A few times a year
A few times a month
Weekly
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
Yes
No
Please list:
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
Carnivore
Other
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
Which of the following goals best fit in with your goals?
Improved health
Improved endurance
Increased strength
Increased muscle mass
Fat loss
What does your current diet look like? Please include calories and/or macros if you know them.
What foods do you dislike?
What is your goal with your training?
Why?
TImeline for achieving your goal.
Rows
2mo
4mo
6mo
8mo
10mo
1 YEAR
NOW
Please rate your motivational level to do what it takes for reach your goal.
1
2
3
4
5
6
7
8
9
10
How many days per week do you exercise?
1-2
3-4
5-6
Have you trained with a personal trainer before?
Yes
No
What kind of training did you do?
At what times during the day do you prefer to train?
Morning
Mid-Day
Afternoon
Evening
Are you currently able to commit to investing time, effort and financial resources into achieving your goals with me as a coach?
Please Select
Yes
No
How often do you want to train per week?
Please Select
1 Session
2 Sessions
3 Sessions
4 Sessions
5 Sessions
6 Sessions
7 Sessions
What are your expectations of me as your coach?
Submit
Should be Empty: