Lifeline Coaching
to be completed before our scheduled call
Today's date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Your age
What is your current frustrating fitness or weight loss challenge?
Weight loss, general
Belly fat
Lack of energy
Loss of muscle tone
Declining strength
Combination of things
Other
On a scale of 1 - 10, 10 being the best, how would you rate your overall fitness level?
If your goal is weight loss, how much weight would you like to lose?
Less than 10 lbs
Between 10 and 20 lbs
Between 20 and 30 lbs
More than 30 lbs
What's your biggest dietary challenge?
Late night eating
I don't like a lot of healthy foods
I love sweets
No real schedule, I eat on the run a lot
Dining out
Other
Complete this sentence: "If only I could _____ I could reach my goals."
Your diet can best be describe as:
Healthy 80% of the time, aside from an occasional splurge
Super strict, this is not an issue for me
Varies day to day according to what's around me
Inconsistent
Other
What's your favorite "cheat" food?
What's your favorite healthy food?
Do you currently strength train?
Yes, regularly (2-3x week)
Yes, but not consistently
No, not at the moment
Do you currently do aerobic exercise?
Yes, regularly (3+x /week)
Yes, but not consistently
No, not at the moment
Do you have access to exercise equipment?
If so, which of the following:
Fitness tubing
Dumbells
Kettlebells
Exercise machines - gym
Exercise machines - home
Cardio equipment (bike, treadmill, etc.)
Other
What approaches have you tried in the past to reach your goals (e.g. diet plans, exercise routines, etc.) and what was the result?
On a scale from 1 to 10, 10 being the highest, what is your level of commitment to making changes and sticking with them?
Do you have any physical limitations? If so, what are they?
Is there anything else you'd like me to know that may help me help you?
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