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Phone Number*
Email*
Full Name*

First NameLast Name
Social media*

InstagramFacebook
Gender*

MaleFemale
Perferred contact option*

TextEmailPhone Call
What custom service would you like*

Custom Online TrainingPersonal TrainingSundressKiller
Date of Birth*

MonthDayYear
Age*
years
Height*
inches
Weight*
Lbs
Ideal Weight*
Lbs
Part 2. Lifestyle Information
Are your pregnant?

YesNo
What do you do for a living?*
What are your main reasons for seeking help?
Whats the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
On a scale of 1-5 with 5 being the highest, how would you rate your stress levels?

12345
On a scale of 1-5 with 5 being the highest, how serious are you about a lifestyle change?*

12345
Why? *
On a scale of 1-5 with 5 being the highest, how would you rate your overall health?

12345
Do you have any known food allergens? If yes, please list them *
Do you smoke?

NoYes, 3 or more days a weekYes, less than 3 days a week
Do you drink?

NoYes, rare occasionsYes, 3 or more days a weekYes, less than 3 days a week
Please list the physical activities that you participate in outside of work: (include duration)
Part 3. Medical and health information
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
if yes please list:
Part 4. Daily Dietiry/ Nutritional Choices
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
How many meals do you typically eat per day?.

12-34-66+
Have you tried any meal plans before?

yesno
What influences your food choices?

TasteConvenienceNutritional factsPriceFamily or friends
Eating patterns? (click all that apply)

Emotional eaterEat too littleEat too muchI don't eat enough veggiesBoredomI choose the best options for meI forget to eatOn the go eatingOther
How many days do you typically prep your meals for at home?

12-34-66+none
Do you grocery shop for the week? If so,where?
Whats your weekly budget for food?
What 3 foods can you never give up?
What foods do you refuse to eat?
How many times do you eat out? What's your favorite restaurant?
How often do you have a bowel movement?
How much water do you drink a day?
Part 4. Fitness Goals (Only fill out if looking for online training)
If you have any injuries, please list them.
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your first 30 day goal with your training?
Why?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you had a online coach before?

YesNo
If yes what kind of training did you do:
What days during the week would you like to workout?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Please Read The Following Terms and Conditions.
1.) Fitness professional

I understand that the team members over at Do You Fitness, LLC are fitness professionals and not doctors. I also understant that a certified nutritionist will be customizing my nutritional needs based on the information I provided.

2.) Payment return policy

I understand that all payments are non-refundable unless I haven't recieved my desired program within 30 days of purcase.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
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I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo

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Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Daily Dietiry/ Nutritional Choices

Part 4. Fitness Goals (Only fill out if looking for online training)

Please Read The Following Terms and Conditions.

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