CONQR Online Training Client Assessment

Full Name*

First NameLast Name

Age*

Gender*

MaleFemaleOther

E-mail*

Phone Number*

Area CodePhone Number

Location*

CityState

What are your top 3 priorities in life right now?*

Ex. My health, my family, and my clients

If a genie specializing in health/fitness/body transformations could grant you 3 wishes, what would they be?*

Its a fitness genie so it can't give you a million dollars

Did you ever play any sports? (Organized or Recreational)

YesNo

If yes, which sport(s) and when?

What are your top 3 favorite junk foods?*

What are your top 3 favorite healthy foods?*

All time favorite movies?*

Remember the Titans, The Lion King, and Braveheart

What's your favorite quote?

There are no limits. There are only plateaus, and you must not stay there, you must go beyond them. -Bruce Lee

Have you had any injuries, surgeries, or limitations that restrict you in any way?*

What are your 3 month fitness goals?*

When did you last feel happy and content with your body and energy levels?*

What drove you to reach out to me? *

Why do you think I can help you?*

What do you think I can help you achieve?*

How committed are you to achieving your health & fitness goals?*

	1	2	3	4	5

1 is Netflix & Twinkies all day!, 5 is I'll have broccoli & planks for lunch.

Are you willing to invest $300 - $500 per month in a coaching program to get to where you want to be?*

YesNo

Is there any other family member or person who has a say in your decision to hire a coach or stick to a fitness program?*

YesNo