Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Year
-
Month
Day
Date
Social Media Handles
Best way to contact you?
Instagram or direct messages
Email
Health & Fitness Goals
What goals do you hope to accomplish?
*
Fat Loss
Increased Strength
Increased Muscle Mass
Weight Gain
Better Digestion
More Energy
Better Sleep
Other
Out of all of these goals, which is the most important to you?
*
Do you have a specific timeline for achieving that goal? If so, please specify:
*
What do you see being the biggest challenges for you to accomplish your goal?
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Consistent Exercise
Diet
Time Management
Meal Planning
Checking in with us
Support from family, friend, coworkers
Staying focused on weekends
Nothing, I'm ready to go
Other
Is there anything else you would like to tell me about your health and fitness goal(s)?
Health Information
Do you have any physical limitations? (asthma, bad knees, back, wrists, etc)
*
Any additional health information you would like to share? (Hereditary diseases, hunches on potential issues, food allergies)
Lifestyle Information
What do you do for a living/occupation?
*
How would you best describe your activity level during the day?
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None, sedentary job, little activity at home
Moderate, light activity during the day and at home
Active, on your feet most of the day but nothing strenous
Heavy, on your feet and doing strenuous activity throughout the day
Describe your work schedule, hours worked, time of day, days per week.
*
When do you typically go to bed?
*
Hour Minutes
AM
PM
AM/PM Option
When do you typically wake up?
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Hour Minutes
AM
PM
AM/PM Option
Describe your wake up routine. Do you need an alarm clock? Do you pop out of bed right away? Basically is waking up hard and how rested do you feel?
*
Fitness, Diet and Nutrition Information
Explain your fitness/exercise routine? What kinds of workokuts do you do? How frequently? Are you working with a trainer currently or have you ever?
Do you take any supplements or PEDs? If so, what supplements and what dosage?
*
Do you follow any dietary guidelines? Vegan, Paleo, Pescatarian, etc? Also explain if you have any known food intolerances or foods you avoid.
*
Macronutrient and Calorie Information
If you are currently tracking calories and macros, how long have you been tracking?
If you are currently tracking and in a calorie deficit, how long have you been eating in a deficit?
Thank you for taking the time to fill out this form and let me know more about you. If there is anything else you would like to let us know about concerning your diet, health, fitness, family, routines, work or whatever please do so below.
Are you ready to Ascend to your BEST self?
YES
no..
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