Tell Me About Yourself!
Please answer all the questions on this form - as your response will help me better understand you and your fitness goals.

After you have filled out this form, I'll contact you with options about when we can chat!
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Full Name *
Email Address *
Phone Number *
Date of Birth *
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DD
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Height *
Do you know your current weight?
Do you have a goal weight?
Tell me about your fitness goal. What do you want to accomplish? (Check all that you want) *
Required
Have you attempted these goals before? Have past attempts succeeded? Why or why not? *
Based on your past experience, what's your biggest obstacle in meeting your fitness goals? *
On a scale of 1-10, how much do you value your health?
It's a low priority
It's my highest priority
Clear selection
On a scale of 1-10, how much time and energy do you CURRENTLY invest in your health?
Not much
It's my top priority
Clear selection
How would you rate your OVERALL fitness level on a scale of 1-10?
Not fit
Very fit overall
Clear selection
How would you rate your CURRENT eating habits on a scale of 1-10?
Poor / Mostly Junk Food
Super Duper Healthy
Clear selection
How often do you eat out?
How would you rate your kitchen / cooking skills?
Barely know a spoon from a spatula
You have a YouTube Cooking Channel
Clear selection
How would you rate your current FLEXIBILITY on a scale of 1-10?
Stiff as a Board
Like a Gymnast
Clear selection
How would you rate your overall STRENGTH on a scale of 1-10?
Not strong
Very strong
Clear selection
How would you rate your overall SELF-CONFIDENCE?
Very low
Very high
Clear selection
If you were in a GYM or fitness setting, how would you rate your overall self-confidence?
Very uncomfortable in the gym
Confident in the gym
Clear selection
How would you rate your daily OUTLOOK on life?
Very negative
Very positive
Clear selection
On a scale of 1-10, how would you rate your stress MANAGEMENT?
Low Stress Management
Great Ability to Manage Stress
Clear selection
How would you rate your energy levels AT WORK?
Low Energy
High Energy
Clear selection
How would you rate your overall SLEEP quality?
Low quality
Great quality
Clear selection
If you could only pick one, which of these would you like to improve the MOST:
Clear selection
How many days per week do you CURRENTLY participate in planned exercise?
Clear selection
What type of exercise do you CURRENTLY do?
What type of exercise interests you?
What kind of fitness equipment do you have access to?
What area of nutrition do you feel like you could improve the most?
Have you made any recent changes to your nutrition?
Are you following any specific diet or nutrition plan at this time? If so, give me some details.
Do you have any food limitations, concerns, or specific allergies? (Vegan, Celiac Disease, etc.)
Do you take any nutritional supplements? If so, list them here.
Do you smoke? *
On average, how much alcohol do you consume weekly? *
On average, how many hours do you sleep per night?
Clear selection
How active are you throughout the day?
Clear selection
Tell me about your job or daily life - What do you do?
How would you rate the mental stress level of your job?
Clear selection
How would you rate the mental stress level of home life?
Clear selection
Of all the things in your life, what do you feel is the biggest source of stress?
Will your current source of stress affect your goals?
Clear selection
Are you currently on any medications that affect your heart, lungs, blood pressure, or heart rate? *
Do you have any injuries or areas of concern that will affect your exercise program? If yes, tell me about them. For example - stiff neck, recent shoulder surgery, chronic knee pain, etc. *
Are there any other limitations to your health, fitness, or well-being that I need to know about? *
Please make sure you have consulted with your doctor or primary care physician before starting any exercise program. *
If you were to start a fitness program this week - what days would you be willing to schedule exercise? *
Required
Do you have a time-of-day preference?
Will you have a workout partner or accountability partner? If so, who?
What are your expectations from me? What do you think my role - as a trainer and coach - can offer you? *
How did you hear about me? *
Making big changes can be difficult. I believe that big changes happen in small steps and it's important to set realistic expectations - we'll talk more about this as we go along. If you were to start this process today, WITHOUT MY HELP, what kind of changes would you make right now to help you reach your goals? *
DISCLAIMER
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness consultation.

Any information provided is not to be followed without prior approval of your doctor. If you choose to use this and future information without such approval, you agree to accept full responsibility for your decision.
Type your name below to sign the above disclaimer. *
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