Welcome!! Please fill out this form, so I can meet you where you are & help you follow your 🌟.
Name
First Name
Last Name
E-mail
*
example@example.com
Best Phone Number
*
-
Area Code
Phone Number
How do you want me to communicate with you?
Phone
Email
Facebook Messenger
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Height
Weight
Are you new to FASTer Way to Fat Loss
Yes, this is a new experience for
No, I am a returning client
other ___________________
Have you utilized Intermittent Fasting before?
No, this is a new experience for me
Yes, I have used 16:8
Yes, have only used 12:12
I have only started to learn about IF—excited to learn
Have you ever tracked Macro Nutrients?
No, I don’t know how.
Yes, but did not have success
Yes, but it has been a while
Are you new to exercise?
Yes
No
Other _________________
Tell me about your current level of physical activity.
Sedentary (no exercise)
Light (1-3 times/week)
Moderate (3-5 times/week)
Active (5-7 times/week)
High Performance (7 times/week)
How many meals/snacks do you eat per day
1
2
3
4
5 or more
How often do you eat out per week including breakfast, lunch, and dinner?*
1
2
3
4
5 or more
How many times per week do you cook meals at home?
1
2
3
4
5 or more
What is your dietary preference?
I eat anything including processed foods
Keto
Pescatarian
Vegan
Vegetarian
Whole Foods
Carnivore
How many hours of sleep do you get most nights?
Less than 6 hours
6-8 hours
More than 8 hours
How often do you wake up at night? What time(s) of the evening? Any particular reason why? (Partner snoring, night sweats, racing thoughts, pain)
Rate your level of stress 1 being low - 5 being high*
LOW
1
2
3
4
HIGH
5
1 is LOW, 5 is HIGH
What is your main goal for these next 6 weeks?
Lose Weight (I'd like to lose 10-20 pounds)
Build muscle while losing fat
Build muscle mass
Improve my Optimal WELLth while I maintain my current weight
Performance (Optimize while I train to support my workouts)
Other ________________
What is your WHY (North 🌟 ) Why are you doing this? Please share as much detail as possible. We are going to be anchoring to our 🌟so try to elaborate as much as you can on your WHY.
Imagine you have a magic wand & you can bring this 🌟 within reach—- how do you feel now that you have reached this goal!! Write out a detailed picture of you & how amazing you feel. (We will turn this into an “ I AM” statement or affirmation) Feel free to create this affirmation down below after your detailed imagery.
What is your biggest struggle regarding your Optimal WELLth at this time?
Pain/inflammation
Night sweats/ hormones
Anxiety/mood
Brain fog/ no energy
Time (lack of)
Share an important event you have coming up that you would like to look your best for and tell me why looking your best is important to you. (Wedding, Birthday, Class Reunion, Vacation, etc)* include a date for this event.
Thank you for trusting me to help you SHOW up for yourself & follow your 🌟
😍 Christine
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