About You.Give me the scoop. I want all the details! If there are any responses you’d like to discuss further, let me know. Name * First Name Last Name Email * Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country D.O.B. * MM DD YYYY Height * Ex: 5' 8" Current Weight * Goal Weight * Goals * Select all that apply Lose weight Build lean muscle / tone up Bulk up / build mass Improve diet Create healthy habits Improve mindset If you had to choose one, which goal is most important to you? Explain. Have you worked with a personal trainer before? Yes No Please rank the level to which you agree or disagree to the following questions. * Achievement of my goals is a priority (urgent). Strongly Disagree Disagree Neutral Agree Strongly Agree I consider myself to be fit and "in-shape" - I work out often. Strongly Disagree Disagree Neutral Agree Strongly Agree I know and understand a great deal about fitness. Strongly Disagree Disagree Neutral Agree Strongly Agree I eat very healthy, my diet supports my goals. Strongly Disagree Disagree Neutral Agree Strongly Agree I know and understand a great deal about nutrition. Strongly Disagree Disagree Neutral Agree Strongly Agree My daily lifestyle and habits are very healthy. Strongly Disagree Disagree Neutral Agree Strongly Agree I have a solid mindset - I think positively most of the time. Strongly Disagree Disagree Neutral Agree Strongly Agree Typically, I feel great - alert and energized during the day. Strongly Disagree Disagree Neutral Agree Strongly Agree I am mostly sedentary during the day (ex: desk job). Strongly Disagree Disagree Neutral Agree Strongly Agree I am ready, willing, and able to put in the effort required to reach my goals. Strongly Disagree Disagree Neutral Agree Strongly Agree Please list and explain any injuries (past included) Please list any health conditions, allergies, or medications I should know about. What equipment do you have at home? DISCLAIMER * Health And Lifestyle coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to replace the services, treatment and/or diagnosis of a licensed professional. As your wellness coach I do not provide a second opinion or in any way attempt to alter the treatment/recommendations of your personal physician. It is my role to work closely with you to provide support and accountability as you create a lifestyle that meets and maintains your health goals. Do you acknowledge? Yes Thank you!
