LAST STEP!! Please Complete This Application
If this form isn't completed we won't be able to complete the call
Personal Details
Name
*
First Name
Last Name
Age
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Body Stats
Current Height
Current Weight
Body Fat Precentage
BMI
Goals
What Is Your Goal? What are you hoping to accomplish? (be specific as possible)
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How soon are you hoping to accomplish this goal?
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Are you doing anything right now to help you achieve this goal? If so, please state
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Challenges
What is your BIGGEST Challenge?
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What have you tried in the past? (Select those which apply)
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Gym Membership
Personal Trainer
Shakes/Supplements/Pills Etc
At home Diets/Workout Plans
Other
What stopped you from achieving your goal AND/OR sustaining it?
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"If we spoke 90 days from today, what would need to happen for you to consider this a success?"
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On a 1 to 10 scale, how dissatisfied are you with your current state? 1=Comfortable 10=Will Do Whatever It Takes To Change.
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1
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9
10
1 is , 10 is
How commited are you to reaching your goal? 1=Not committed 10=Will Do Whatever It Takes To Change.
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1
2
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5
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9
10
1 is , 10 is
Is your spouse supportive of your health goals?
Please Type the word "YES" if you agree with the above statement
*
Please Type "Yes" To The Following Statements If You Agree
*
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