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Welcome to the STRONGHOLD Coaching Academy
Please take a moment to fill out this form to help me better serve you.
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1
Name
First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
Where do you live?
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5
What is your current age?
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6
What is your height ?
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7
What is your current weight ?
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8
How Much Weight Do You Want to Lose
0-10 lbs
10-20 lbs
20-30 lbs
30-50 lbs
50 or more lbs
I want to gain weight
Other
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9
What are your primary goals ?
Lose 20 lbs or LESS
Lose 20 lbs or MORE
Decrease Bodyfat
Improve Fitness
Get off Medications
Lose Belly fat
Tone Up
Improve my Health
Improve my self-image
Other
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10
What are your top 3 Goals?
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11
How would you rate your current fitness level
Beginner
Intermediate
Advanced
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12
Do you currently follow a workout routine? Please describe
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13
How many days do you want to train
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2
3
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5
6
7
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14
Any medications? Please list
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15
Any health issues ?
Diabetes
Blood Pressure
Cholesterol
Depression
Cancer
Joint Pain
Other
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16
What has prevented you from achieving your goals ?
Guidance
Accountability
Support
Consistency
I quit on myself
I have hit a plateau
Procrastination
Poor food choices
Not enough exercise
Emotional / Stress Eating
Other
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17
On a scale from 1-5, how ready are you to make this change?
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2
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5
Not Ready :(
I AM SO READY
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18
Are you willing to invest financially, emotionally, and with time and energy to accomplish your health & fitness goals?
Yes I Am Ready to Change My Life
No I will just stay stuck
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19
What is the biggest lie you tell yourself ?
(I'm too old, I'm too lazy, I will always be heavy, etc)
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Anything Else You Want Me to Know?
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