Push Forward Be Better Intake Form

We want to help inspire you to Push Forward and Be Better everyday by living a healthier lifestyle with the help of our personalized fitness and nutritional programs.

By completing this form you will help us understand your wellness goals and needs to enable us to create a plan that is tailored to you.
Name*

First NameLast Name
Email*
Phone Number*

How is your energy throughout the day?*

	1	2	3	4	5	6	7	8

1 is Always Tired, 8 is High Energy All Day

Describe your mood throughout the day.*
Tell us how you generally feel during your day. Are you tired, energetic, melancholy?
What is your diet like? Describe the foods that you consume regularly. *
Do you have any favorite foods, any foods that you consume regularly?
How many times do you eat a day? (Including snacks)*

3 Times4 Times5 Times6 TimesOther
When you think of protein what comes to mind?*
When you think of Carbs what comes to mind?*
When you think of Fat what comes to mind?*
Tell us about your Goals*
What are your health and wellness goals? Any extra information you want to add here will help us understand how we can help you.
Current Weight *
Goal Weight *
What has been your biggest fitness challenge?*

Staying MotivatedAccountabilityLack of TimeGetting StartedTaking my results to the next levelOther
How much experience do you have with exercising?*
Do you have any favorite exercises?*

Weight TrainingHigh Intensity Interval Training (HIIT)Running and/or sprint drillsSwimmingRoad CyclingYogaPilatesNot sure yet

Level of Fitness*

	1	2	3	4	5	6	7	8

1 is Not Athletic, 8 is Elite Athlete

What is your level of commitment to reaching your goals?

	1	2	3	4	5	6	7	8

1 is Thinking About it, 8 is Must Do This!

How many days a week can you commit to your fitness?*

1234567
What can we help you with?*

NutritionStrength & Conditioning1:1 Coaching*Personal Fitness ProgramMobility/ StretchingGym DesignOther
Do you have any health conditions/special circumstances that effect your nutrition or your physical abilities?*
Please be as detailed as possible.
Do you have any physical limitations? *
If you have any physical limitations or have had any recent surgeries you will need approval from your general practitioner to begin a physical fitness program. If you have any health conditions we will need to have an understanding of those conditions before we create a nutrition or fitness program.
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