TONED BY KIM - CLIENT INTAKE FORM

TONED BY KIM - CLIENT INTAKE FORM
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Instagram Handle (Let's connect!)
Facebook Handle (Let's connect)
Where did you hear about us?
Please mention your referrer's name/business to get an exclusive discount if you have one.
Date of Birth

MonthDayYear
Height
ft
Weight
lb
Target Weight
lb
At what times during the day would you prefer a 30min consultation?
What do you do for a living?
Do you follow a regular working schedule, do you work days, afternoon or nights?
What is your Activity Level per Week?
What are your Priorities?
Please list the physical activities that you participate in outside of the gym and outside of work.:
Your current diet could be best characterized as:
What TBK programs would you interested in?
What do you expect from me as your coach?
Are you experiencing any stress or motivation problems?
What is your goal with this program?
How soon are you ready to Start?
If you have any diagnosed health problems list the condition(s):
Have you had any surgeries related to pregnancy, childbirth, or the abdominal area?
If Yes, please briefly describe the surgery and approximate date(e.g., C-section, hernia repair, abdominal surgery)
Date of Inquiry

MonthDayYear
Date
Should be Empty: