Weight Loss Coaching Consultation Form
Date
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Month
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Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birth Date
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Month
-
Day
Year
Date
Height (in's)
Weight (lbs)
My main goals are focused around
Weightloss
Muscle gain
Strength gain
Athletic performance
Other
List your specific goals from 1-3 in importance
What would you like to accomplish during this during the 12 week weight loss coaching program?
What foods do you have a hard time saying no to?
Do you have any food allergies or intolerances? If yes, list below.
Do you take any supplements or vitamins? If yes, list below.
What are some of your favorite foods and beverages?
Do you have any concerns with your current eating habits? If yes, explain below.
Do you have any barriers to healthy eating, or changing your eating behavior? If yes, explain below.
Are you interested in Individual or Group Coaching or Both?
How will you be paying for services? (Self-Pay or Insurance)
Please Select
Self Pay
Insurance
Are you a current participant in 1:1 Coaching with Curly Gainz Fitness?
Please Select
Yes
No
I would like more information about 1:1 coachin
If planning to use health insurance: Attach a copy of your Driver's License/ State ID & Insurance Card. (This will allow us to verify your insurance and determine your coverage)
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How did you hear about us?
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