AlcineXtreme Fitness
Note: AlcineXtreme Fitness is a fitness company with clients world wide. But when a client has dramatic change, AlcineXtreme travels to do a meet and greet. You might be next.....
Tell me more about yourself
By learning more about your lifestyle and your habits, I can take better care of your and make sure virtual training is a good fit for your goals and individual needs.
Name
*
First Name
Last Name
Date of Birth
*
Gender
*
Height
*
Where did you hear about AlcineXtreme Fitness, LLC?
*
TikTok
Facebook
Instagram
Friend
Other
Current Weight
*
Are you a member AlcineXtreme Operation TransformHer/Him Facebook Group?
Yes
No, Please join today! www.facebook.com/groups/alcinextremeoperationtransformherhim
Staying in touch
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
What time zone do you reside in?
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Eastern
Central
Mountain
Pacific
Other
How do you prefer me to contact you?
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Email
Phone
Video Chat
Text
What do you want?
In general, what are your goals? Check all that apply
*
Lose weight/fat
Gain weight
Maintain weight
Add muscle
Improve overall health
Improve physical fitness
Look better
Feel better
Have more energy and vitality
Healthy aging
Get control of eating habits
Get stronger
Physique competition/modeling
Improve athletic performance
Get off or decrease medications
Other
What do you want to change?
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Out of all the changes you'd like to make, which ones feel most important/urgent?
*
Have you tried anything in the past (or recently) to change habits, your health, your eating, and/or your body? If so, what?
*
Which of those things worked well for you, and why? (Even just a little bit, and even if you might not be doing them right now.)
*
Which of those things didn't work well for you, and why not?
*
If you were to consider maybe making more changes to your habits, your health, your eating and/or your body, what might those be?
*
Until now, what has blocked you or held you back from changing these things?
*
What are you doing right now?
Right now, how would your rank your overall eating/nutrition habits?
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1
2
3
4
5
6
7
8
9
10
Horrible
Awesome!!
1 is Horrible, 10 is Awesome!!
Are you regularly active in sports and/or exercise
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Yes
No
If so, approximately how many hours per week?
Fewer than 5 hours
5-9 hours
10-14 hours
15-19 hours
20 or more
What type of sports and/or exercise do you typically do?
*
Approximately how many hours a week do you do other types of physical activity? (e.g. housework, walking to work or school, home repairs, moving around at work, gardening)
Fewer than 5 hours
5-9 hours
10-14 hours
15-19 hours
20 or more
What other types of movement and/or activities do you do?
*
What's around you?
Who lives with you? Check all that apply.
*
Spouse or partner(s)
Roommate(s)
Child(ren)
Pet(s)
Other family (e.g. parent, grandparent, sibling, etc.)
Do you have children? If yes, how many and what are their ages?
*
Who does most of the grocery shopping in your household? Check all that apply.
*
Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family
Who does most of the cooking in your household? Check all that apply.
*
Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family
Who decides on most of the menus/meal types in your household? Check all that apply.
*
Me
Spouse or partner(s)
Roommate(s)
Child(ren)
Other family
Right now, how much do the people and things around you support health, fitness, and/or behavior change?
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1
2
3
4
5
6
7
8
9
10
Not at all
Completely
1 is Not at all, 10 is Completely
What's your health like?
Have you ever been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?
*
Yes
No
Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?
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Yes
No
Right now, are you taking any medications, either over-the-counter or prescription?
*
Yes
No
On a scale of 1-10, how would you rank your health right now?
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1
2
3
4
5
6
7
8
9
10
Worst
Awesome!!
1 is Worst, 10 is Awesome!!
Why?
How are you spending your time?
In an average week, how many hours do you spend....
In paid employment
Taking care of others (e.g. children, person with disability, older person?
At school or doing school work?
Doing other unpaid work? (e.g. housework, errands)
Traveling and/or commuting?
Volunteering?
Adding up all these things, how many total hours per week do you spend doing all these activities?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
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1
2
3
4
5
6
7
8
9
10
My life is panicked and insane
My life is completely calm and relaxed
1 is My life is panicked and insane, 10 is My life is completely calm and relaxed
How is your stress and recovery?
Think about all the activities you're involved in (e.g. work, school, caregiving, housework, travel). Then assess as best as you can: Given all the demands of your life, what is your typical stress level on an average day?
*
1
2
3
4
5
6
7
8
9
10
No stress
Extreme stress
1 is No stress, 10 is Extreme stress
On average, how many hours per night do you sleep?
*
4 or few hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
How do you normally cope with your stress?
How ready, willing, and able are you to change?
Right now, on a scale of 1-10:
How READY are you to change your behaviors and habits?
*
1
2
3
4
5
6
7
8
9
10
Not at all
Completely
1 is Not at all, 10 is Completely
How WILLING are you to change your behaviors and habits?
*
1
2
3
4
5
6
7
8
9
10
Not at all
Completely
1 is Not at all, 10 is Completely
How ABLE are you to change your behaviors and habits?
*
1
2
3
4
5
6
7
8
9
10
Not at all
Completely
1 is Not at all, 10 is Completely
What do you expect?
What do you expect from as your coach/trainer?
*
What are you prepared to do to work towards your goals?
*
What are you interested in?
*
Virtual Personal Training
Nutrition
Both Virtual Personal Training and Nutrition
Challenge Group
What type of program will you prefer?
*
Gym Program
Home Workout Program
Home & Gym Program
Why do you want to be healthy? (This is your "Why" statement)
*
Disclaimer
Please recognize that it is your responsibility to work directly with your health care provider before, during and after seeking nutrition and/or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
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