Nutrition Coaching Application

I am so glad you are ready to level up your nutrition and fitness game.  Please fill out the below and once it is submitted, I will be in touch with you within 24hrs with your next steps to start planning for your transformation.

I truly believe that if you change your mind, body and lifestyle, you change your quality of life and I am excited to help you learn how to reach your goals…all you have to do is commit.

If you have any information you would like to add to this, please send an email to me at cheryl@positiveimagefitness.ca

Thank you for choosing me to be your coach and let’s get you living your best life.

Talk soon

Cheryl


DISCLAIMER: please recognize that it is your responsibly to work directly with your health care provider before, during and after seeking any nutritional and or fitness advice. If you choose to use this information without approval, you agree to fully accept responsibility for your decision.


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First and Last Name *
Phone Number *
Email *
Your birth date *
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Your age
Your Height
Your current weight
What do you want?  In general, what are your goals?  Check all the apply *
Required
Out of all the changes you would like to make, which ones feel the most important/urgent *
Have you tried anything in the past or recently to change your habits, your eating and/or your body?  If so, what? *
Which of those things worked well for you and which of those things didn't work well and why? *
Until now, what has blocked you or held you back from changing your habits, your health, your eating and/or body? *
Right now, how would you rank your overall eating/nutrition habits?
1 being horrible
5 being awesome!
 *
Are you regularly active in sports or exercise?  If so, approx. how many hours per week *
Who does most of the grocery shopping in your household? *
Who does most of the cooking in your household? *
Who decides on most of the menus/meal types in your household? *
Right now, how much do the people and things around you support health, fitness and /or behaviour change?
1 being not at all
5 being completely on board
 *
Right now, do you have any specific health concerns, medical conditions, pain or injuries?  Are you taking any medications either over the counter or prescription? *
On a scale of 1-5 how would you rank your health right now?
1 being worst ever
5 being awesome
 *
On a scale of 1-5 how do you feel about your schedule, time use and overall busy-ness?
1 being my life is packed and insane
5 being my life is calm and relaxed
 *
On average, how many hours per night do you sleep? *
How do you normally cope with stress? *
How READY, WILLING and ABLE are you to change your behaviours and habits?
1 being not at all
5 being completely
 *
What are you prepared to do, to work toward your goals? *
Are YOU willing to invest money to finally sculpt your physique and have a better relationship with food?
 *
How did you hear about Positive Image Fitness and the Lift Yourself LEAN program *
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