General Information
Name
First Name
Last Name
Email
example@example.com
Instagram Handle
How did you hear about JaLynn Lifestyle?
Please confirm your program preference:
Please Select
1 Year Nutrition Only / Monthly Payment
6 Months Nutrition Only / Monthly Payment
3 Months Nutrition Only / Monthly Payment
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Height
Current Weight
*Please weigh yourself first thing in the morning, empty stomach.
GOALS
What are your short-term health/fitness goals?
What are your long-term health/fitness goals?
What has been the biggest barrier in your ability to reach your goals?
LIFESTYLE
Job Description
Sedentary or active job? Hours per week?
Are you able to pack and eat your meals at work?
Yes
No
Are you married/in a commited relationship?
Yes
No
Do you have children?
Yes
No
On average, how many hours of sleep to you get each night?
On average, how many ounces of water do you drink each day?
MEDICAL/HEALTH
Do you have any diagnosed health conditions I should be aware of?
Are you taking any medications?
Please list medications.
What supplments are you currently taking? (vitamins, pre-workout, etc)
Please list what you are taking, when you are taking it, dosage.
When was your last menstrual cycle? (if applicable)
NUTRITION
Are you seeking out a meal plan or macro plan?
Meal Plan
Macro Plan
What is your current diet? What does a typical day of eating looking like for you? If previously following macros, what were your target macros?
Do you have any food allergies, food sensitivities or dietary restrictions?
Please list a few of your favorite foods.
Please list the foods (if any) you refuse to eat.
ACTIVITY
What time of day do you normally train?
Morning
Mid-Day
Evening
It varies
How frequently are you engaging in cardiovascular exercise per week? Please describe what you are currently doing right now (type of cardio, time, frequency).
How frequently are you engaging in resistance training each week?
1 day
2 days
3 days
4 days
5 days
6 days
7 days
I don't currently engage in resistance training
Additional Information
Is there any other information you would like to share with me?
Please attach a front, side and back photo of yourself.
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Ladies, please wear a bikini or sports bra and shorts. Men, please wear trunks/shorts.
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