Client Form
Are you ready to make a lifestyle change? If you truly are committed to making a change in your life and ready to invest in yourself please fill out this form to help me get to know you and understand where you currently are.
Name
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Weight (pounds)
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Address:
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Afghanistan
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Country
Did someone refer you to me? If so who?
First Name
Last Name
Which plan are you interested in?
$275 Workout Program/Macros-4 weeks
$200 Macros/Daily Habits- 4 weeks
$100 Customized Workout Program
Goals
Gain Muscle
Fat Loss
Gain Strength
Lifestyle Change
Build Confidence
Develop Healthier Habits
Improve Healthier Relationship with Self
Out of the above answers other than your main goal, is there anything else you want to work on?
Describe your goals:
What is your current exercise routine? If you have an Apple Watch how many steps a day? (Cardio, resistance training, time/times per week)
What does your current diet look like? (Sending a food log would be helpful!)
Do you have any previous injuries or surgeries?
Do you have any exercise limitations I should be aware of?
Please describe an average day for you; current occupation/activity level
Realistically, how many days a week would you be able to fit in a 45-60 min workout?
Are you looking for a home or gym based plan?
Please Select
Gym
Home
Taking any medications, currently?
Yes
No
If yes, please list it here
This product requires for you to download the app trainerize to work with me, do you have apple, Samsung, or android?
Anything else I should know about you OR do you have any questions for me?
Do I have your permission to use pictures or feedback on social media?
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Yes
No
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Please list your Venmo/Cashapp/PayPal (for monthly payments)
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Signature (all purchases are final sale and non refundable)
First Name
Last Name
My Products
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Macro Plan/Workout Program
$
275.00
App access, Work out plan, 24 hour support, Education, Baseline nutrition (customized macros), biweekly checkins, support group, grocery list, daily habits
Macro Plan
$
200.00
Customized Macros, daily habits, weekly or biweekly checkins, app access
Customized Workout Program
$
100.00
Customized Workout Program catered to your goals
Enter coupon
Apply
Total
$
0.00
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