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1:1 Coaching Intake Form
Hi! Thanks so much for your interest in my 1:1 Coaching Program! Please complete the form below so I can get a better idea of how to help you reach your health and fitness goals.

xx Demps
Name *
Email *
Phone Number *
Age *
Height *
Current weight *
Would you like your weight to be different? If so what? *
Where do you feel like you need the most support? *
Tell me about yourself! What challenges are you facing in terms of your health and fitness? What is working for you? What isn't? *
At what point in your life did you feel your best? *
What are your TOP 3 health and wellness goals? *
What have your tried in the past to reach these goals? Be specific. *
Why is it important that you reach these goals? *
Do you have a gym membership? If not, what equipment do you have available to you at home? *
Tell me about your current workout routine. What do you do on a weekly basis? What types of workouts do you enjoy? What don't you like? *
How is your sleep? *
Awful
Sleep like a baby
How is your digestion? *
Lots of digestive issues
No problem here!
Do you take any supplements or medications? If so, please list. *
Tell me about your diet. What do you eat in a typical day? What challenges are your facing? *
What percentage of your food is home-cooked? *
Do you crave sugar, coffee, cigarettes, or have any major addictions? *
The most important thing I should do to improve my health is .....? *
Do you have any injuries, previous surgeries, etc that I should know about? *
What makes you most excited about working with a coach? *
Anything else you would like to add? Any questions? *
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