SWISH Fitness

Are you looking to lose weight?

Make changes in your diet?

If you are ready to make the changes necessary to live the life that you DESERVE than I will provide all the systems and programs that you need; to not only lose weight in the next 90 days,but also help you create the mindset and habits necessary to sustain the weight loss for life!

Name

First NameLast Name

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

What are your Fitness & Nutrition goals? (Checktop 3 most important goals)

What is keeping you from achieving your Fitness& Nutrition goals? (Check all that apply)

What motivates you? (Check all that apply

Do you follow a current exercise regime?

If you answered "Yes" to the last question, please describe:

Are there any physical limitations or medical conditions that would inhibit or limit your participation in an exercise program?

Have you ever done personal training before?

If you answered "Yes" to the last question, please describe:

What do you expect from a personal trainer?

What activities/exercises do you currently participate in? (Check all that apply)

What is your current activity level?

What activities/exercises have you participated in the past? (Check all that apply)

What was your past activity level?

Height

Weight

Have you had any recent weight gain/loss?

If you answered "Yes" to the last question, please describe:

List your top 3 nutrition concerns:

Tobacco Use

Alcohol Use

Do you take any vitamins, minerals or supplements? If so, please explain:

List current medication and reason for taking:

How often do you eat?

How often do you eat out?

Are you currently on a special diet? If Yes, please explain:

Have you ever had a nutrition assessment done before? If Yes, please explain:

If you are ready to begin the next phase in your life, click submit below so we can review your application form!