Stay Balanced Online Coaching Consultation Form.
Full Name
First Name
Middle Name
Last Name
Gender
Please Select
Female
Male
I would rather not specify
Age
Date Of Birth (day/month/year)
Height (cm)
Weight (kg)
What is 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, afternoons or nights?
If you have any diagnosed health conditions please list them below.
If you have any injuries (past or present) please list them below.
Out of the following goals what best fits with your goals? (You can pick more than 1)
Improved Health
Improved Endurance
Increased Strength
Increased Muscle Mass
Fat Loss
Are you currently exercising regularly? (At least 3 x per week)
Yes
No
How often are you willing to train a week?
1
2-3
3-4
4+
Please rate your motivational level and readiness for change (10 being sign me up, I am ready to go!)
Please Select
1
2
3
4
5
6
7
8
9
10
What date and times are you available over the next 7 days for a 15-minute consultation call? Please provide two options below.
Please leave your phone number and email below to be contacted.
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