Fitness Profile for EXtreme Personal Fitness

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EXtreme Personal Fitness

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New Client Information
Name*
Primary Phone Number*

Area CodePhone Number
What is your primary number? (home, cell, work)*

Home NumberCell PhoneWork NumberOther
Secondary Phone Number

Area CodePhone Number
What is your secondary number? (home, cell, work)

Home NumberCell PhoneWork NumberOther
Please tell me any information that I may need to know about either of your phone numbers.
Email Address*
What is the best time for me to reach you? I will ALWAYS send you a text message or email FIRST unless you otherwise indicate. *
What city, state, and country are you from?*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Please tell me the reasons why you have contacted EXtreme Personal Fitness Check all that apply.*

Personal Fitness TrainingWeight Loss/Fitness Coaching Program
How did you hear about EXtreme Personal Fitness?*

FacebookInstagramLinkedinFriends or FamilyChurchGoogle SearchYou met me out somewhereWe are old friends :)Other
Appointment
Let's Achieve Your Goals Together
How long has it been since you have worked out, weight trained, or exercised and done some cardiovascular exercise aka cardio?*

3 months6 months1 year2 years3 years5 years or moreI have currently been doing cardioI have never done any cardio before
How long have you been waiting for this right moment to get started on your fitness/weight loss goals?*

3 months6 months1 year2 years3 years5 years or more
What has inspired you to contact me and get started on a fitness/weight loss program with me?*

Upcoming event (wedding, vacation, birthday)Desire to look better for datingYou are uncomfortable with clothes size/body sizeYou are tired of being/feeling tired (low energy)Doctor prescribed & recommended (health issues)Reduce stress & improve quality of lifeYou have not been seeing resultsYou need more motivationYou haven't been consistent with your workoutsNot sure what to do to achieve goals
Please explain ALL of your answers in the previous question of what inspired you to start a fitness/weight loss program. *
Please check ALL that apply.*

You need more MOTIVATION.You are not sure what to do by yourself.You need better results than what you have been getting.You have not been achieving your goals.You need more energy.You need to be held ACCOUNTABLE.You need more support and encouragement.You need more self confidence & self esteem.You are not happy with your current body weight and/or body fat percentage and BMI.You DESIRE to look better and feel better.
What are your GOALS? *

Lose weight and burn fatFirm and toneGain lean muscleIncrease energyDecrease stress levelsImprove cardiovascular healthIncrease enduranceSleep betterFeel better about yourselfImprove self esteem & self confidenceImprove overall healthOther
Please explain to me exactly what your weight loss or fitness goals or health goals are.*
Why is it important for you to achieve your goals NOW?*
What are the biggest challenges that have stood in your way from achieving your goals?*

You are unsure about what to do in your exercise program.You need more MOTIVATION.Trying to find ways to fit it into your scheduleYou need more patience to stick with the program long term.Emotional support (from family and friends)Your Diet & Eating PlanProcrastinationHaving kids takes up my timeConvenience (gym too far away)Discipline and need to be held ACCOUNTABLEStaying CONSISTENT with your workoutsOther
How soon would you like to achieve your fitness/weight loss goals?*

3 - 6 months6 - 12 months12 to 18 months18 to 24 months24 months or longer
Take Action Today!!

I'm looking for ACTION takers!!! Please tell me that you feel ready to take action and start this program immediately.
Please tell me "Yes I'm all in!!" This way I know you're really truly feeling ready to take action!!*
When it comes to losing weight and getting in shape, please tell me what is your #1 goal?*
Please explain every answer you chose in the last question and "When it comes to losing weight and getting in shape, what do you feel are your biggest problems and challenges?"*
When it comes to losing weight and getting in shape, please tell me what is your #1 and biggest fear??*
When it comes to losing weight and getting in shape, please tell me what are 3 things that you really want to know?? (Besides everything else that you have told me so far.)*
If you could instantly solve one of these 3 problems, challenges, or anything that you have told me so far, what would it be and why??*
How do you honestly feel when you start thinking about losing weight and getting in shape?*
How do you honestly feel about your overall appearance?? How do you feel when you think about your overall appearance?? How do you honestly see yourself??*
What will your life be like 3 to 6 months from now if you don't take advantage of this opportunity to achieve your goals?*
If you have any comments please feel completely free to leave them here.
Thank you for your inquiry to

EXtreme Personal Fitness

I will connect with you shortly.

#TeamAwesome

Let's Start Your Program Today!

Please remember to click submit at the bottom

Thank you!

Kel Silas CPT MHT

EXtreme Personal Fitness
Please enter the message as it's shown in the box.*
Meet Deb Florhe Hughes

She lost 15 pounds!!
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