WELLNESS PROFILE
Full Name
*
First Name
Last Name
Date of Birth
*
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Day
Please select a year
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Year
Sex
Male
Female
Phone
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Instagram Handle
*
How would you like me to contact you?
Email
Text
Instagram
Age
years
Height
ft
Current Weight
*
lb
Target Weight
*
lb
How much weight do you want to loose / gain?
*
lb
Do you eat three meals a day?
Yes
No
Other
Do you eat health snacks?
Yes
No
Other
Daily water intake daily?
8oz - 1/2 gallon
1/2 gallon - 1 gallon
What else drinks do you consume 2+ a week?
Tea
Juice
Soda
Alcohol
Coffee
Energy Drinks
Other
What is your energy level (on a scale from 1-10 ) currently?
What do you do for a living?
Do you follow a regular working schedule, do you work days, afternoon or nights?
What is your Activity Level per Week?
Inactive
Active (3)
Moderate (1-2)
Very Active (4+)
What are your health goals?
Lose Weight
Lean and Tone
Build Muscle
Overall Health
If you have been diagnosed health problems list the condition(s) please list them.
If you have any injuries, please list them.
Are you experiencing any stresses or motivational problems?
Yes
No
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
What are your expectations of me as your Coach?
*
How soon are you ready to Start your DAY 1?
Today
This Week
Next Week
Next Month
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