Fit MOM's 21 Day Reset Questionnaire

Welcome to The Fit MOM 21 Day Reset! We are so ready to RESET after this challenging year, and kick-start 2021 with 21 days of discipline, focus, self-care and oh so much fun! Please take the time to go through this questionnaire and be as detailed as you wish. It's important to us that we get to know you.

Here is what the Reset includes!

Fitness Reset: 6 free LIVE fitness classes (2 per week)!
Nutrition Reset: Choose from 3 different nutrition goals!
Energy Reset: Sleep & start-your-day-right challenges!
Relationship Reset: 7 awesome at-home date ideas!
Motherhood Reset: Daily encouragement quotes!
Stress Reset: 2 free custom meditation videos!

Additional 21 Day Reset benefits:
2 Certified Personal Trainers to lead the Reset and help YOU along the way!
21 Day Reset Facebook community group!
All workouts will be recorded and posted in the Facebook Group!
Connection posts in the Facebook groups so you can meet other moms!

We look forward to better serving you and your specific needs using the answers you provide us below.  If you have any questions, email us at fitmomsonthemove@gmail.com.

Yours in health,
Drea & Brit
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Are you currently pregnant or trying to get pregnant? *
What are your kids first names and birth years? *
Where do you live (City, State)? *
Briefly describe any complications you experienced with any pregnancy. *
Briefly describe your labor and delivery experience with each child. *
Briefly describe any aches, pains, sensations, feelings of pressure or complications you are currently experiencing.   If you know your current abdominal separation (diastisis recti), please also list it here.
Are you taking any medications?  If so, list the name and condition it is treating.
Check any conditions that apply to your medical history: *
Required
Please list anything else we should know about your medical history (injuries, surgeries, etc).
Emergency Contact Name *
Emergency Contact Phone Number *
What are you hoping to get out of this 21 day challenge?  What are you most excited about? *
How did you hear about the 21 Day Reset? *
I have read and agree to the Fit Moms on the Move, LLC Release and Waiver of Liability (view here: https://docs.google.com/document/d/1BvGMqCzoSD-UZb4dloqBgWsEpE-2WxbRQydbZfW1TrU/edit?usp=sharing) *
Required
Today's Date *
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Signature (Type your name below) *
Email Address *
NOTE: Pay attention to the confirmation screen after you click "Send"!  It includes the link to the private 21 Day Reset Facebook group WHICH YOU NEED TO CLICK! :)  Once you're in, be sure to read through "Welcome" pinned post from Dec 1st to get all of the 21 Day Reset details!
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