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First Name
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Last Name
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Email Address
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Birthday
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What is the biggest change you want to make in your health in the next 3 months?
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What is your "Why?"
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On a scale of (poor) to 10 (excellent), how would you rate your satisfaction with your current physical activity level?
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1
2
3
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5
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9
10
What are your Health or Fitness Goals?
Please let me know below, so that I can determine if we are good fit.
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Which of the following are most important to you/reflect your values?
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Family
Career
Fitness
Health
Spirituality
Life Purpose
Leisure Time
What's the single-most important dream you've been putting off?
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What's standing in the way of achieving that dream?
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Time
Money
Don't know where to start
Support
Resources
Other
Other
Think of your biggest supporter(s). If someone were to write a one-sentence story about you, what would they say?
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When are you looking to get started with Coaching?
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Today, I am super motivated and ready to change! LETS DO IT !
Next week. I want better health, but maybe next week.
Next month. I want better health, but I don't want to change right now.
Are you willing to invest at least $250 - $500 a month in your health? Month to Month and Package Options are available.
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Yes, my health is a important to me.
No, my health is not a priority to me.
Any Health-related issues or Illness I should know about?
Diabetes, injuries, eating disorders, high cholesterol, etc..
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Describe current or any previous physical limitations (i.e., knee pain, limited mobility, lower back pain, etc.)
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What is stopping you from reaching your goals?
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Have you worked with a Fitness/Nutrition Coach before?
Can you tell me about your experience?
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What are your goals/expectations of coaching? Any questions for me?
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Are you currently working out?
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Yes
No
How would you rate your activity level?
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Sedentary (desk job/no activity): Most of your day involves sitting.
Lightly active: Some Light walking and standing.
Moderately Active: Walking and standing fora good portion of your day.
Very Active: Walking and standing for nearly all of the day.
Intense: Job consists of picking thing up and heavy labor.
How often do you Train - Lift The Things?
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How much cardio do you do and what type?
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Do you leisure walk?
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Yes
No
If you answered yes to the Leisure Walk question, how many times a week and for how long? Do you get 7,000 to 10,000 steps a day?
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Describe the types of workouts/daily activity you are currently doing? (If applicable)
Examples: Cardio, weight training, yoga, Pilates, group fitness classes, running, biking, swimming, etc.
Include recreational activities like hiking, walking, dancing, etc.
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What did you most enjoy?
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What do you do for employment?
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How many diets have you been on?
When was your last diet?
Are you currently dieting, if so, what are you doing and for how long?
Please list your Competition history if applicable and any information pertaining to competing.
Please describe in full detail. Leave no stone unturned!
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Do you have access to a gym or have gym equipment at home?
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Yes
No
I have a gym membership
I have fitness equipment at home, such as dumbbells, bands, etc..
On a scale of 1 to 10, how committed are you to change/to a healthy lifestyle?
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1
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5
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8
9
10
How did you hear about me?
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Facebook
Friend
Instagram
Google Search
My Website
Other
Other
Anything else you'd like me know?
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