Coaching Interest Application

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Thank you for your interested in working with me.

Please complete the following coaching application to the best of your ability providing as much information and transparency which will allow me to determine if you might be the best fit for my coaching services.

If you want to know more about my coaching services check out my website - https://med3fitness.com/online-fitness-nutrition-coaching/

Email *

Address (optional)

Full Name

Phone Number

Where do you live? (state or country) Include timezone

What specific days and time ranges would work best for you to have a coaching call?

Gender *

Male

Female

Age *

Birthday

YYYY

Height *

Current Weight *

Goal Weight *

Medical Issues or other concerns

No Medical Issues

Hypothyroid

Hashimoto

Hyperthyroid

PCOS

Nursing/Pregnancy

Peri-Menopause

Menopausal

Post Menopausal

Diabetes

Gastic Bypass or Lap Band

Eating Disorder

Binge Eating (current or in the past)

Other:

Activity Level *

Sedentary: No exercise, maybe 1 - 2 days of activity, very little movement.

Light Activity: Desk job, with 2-3 days of activity or exercise per week.

Active: Standing job (server, teacher, nurse) with 4-5 days exercise per week.

Very Active: Manual labor (dancer, mechanic, landscaper) with 6-7 days exercise per week.

High Active: Intense manual labor (farmer, mason, roofer) with 7 days exercise per week.

What do you do for work and do you mostly stand or sit?

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