Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
What is your current age?
*
What is your height ?
*
What is your current weight ?
*
What Do you currently do for work & How active is your job?
*
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
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
Any health issues ?
*
Diabetes
Blood Pressure
Cholesterol
Depression
Cancer
Joint Pain
None
Other
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
On a scale from 1-5, how ready are you to make this change?
*
1
2
3
4
5
What best describes your primary goals in the next 12 months?
*
Become the best version of myself
Get healthier
Get toned and defined
Feel better in my own skin
Be able to wear a bathing suit and feel good about what I see in the mirror
Lower my bodyfat %
Other
When you look in the mirror do you like what you see? Why or why not?
Anything else you want me to know?
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