Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Number
*
-
Area Code
Phone Number
What is your expectation for your health and fitness on this journey?
*
Do you have any dietary issues/ restrictions
*
Are you looking for immediate results or long term lifestyle changes?
*
What do you do for a living?
*
Is health and fitness one of your top 3 priorities in your life over the next 6 months?
*
Other than health and fitness what are the 2 most important priorities in your life over the next 6 months?
*
Do you have any preexisting medical conditions?
*
Do you take any medications?
*
Do you have/use Google docs?
*
Have you worked with a coach in the past?
Are there specific types of fitness that interest you?
Are there any movements or activities that a health professional has told you to AVOID?
Please rate on the scale truthfully (1=Poor to 10=Excellent)
*
Rows
1
2
3
4
5
6
7
8
9
10
Sleep
Nutrition
Stress
Fitness
Time Management
How many hours of sleep on average do you get per night
*
Do you:
*
Rows
Yes
No
Drink caffeine daily
Drink alcohol more than once a week
Smoke ciggarettes/vape
Doomscroll
Drink soft drinks/eat candy regularly
Cannabis
Other substances
Please answer the following truthfully
*
Rows
Confident
Somewhat Confident
Not Confident
I'm prepared to use accountability measures to keep me on track
I'm prepared to fill in my training program
I agree to be used in promotional/social media content
I'm prepared to modify my diet
I'm prepared to modify my lifestyle habits
How did you hear about Live-Wells coaching services
Social Media
Search Result
Word of Mouth
A Current Client
Other
Signature Required
*
Signature provided by Client
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