Request edit access
New Client Consultation Form
Fill out and submit 24 hours before scheduled info session to receive FREE $30 gift!
Email address *
Name *
Your answer
Date *
MM
/
DD
/
YYYY
Tell us a little bit about yourself. What do you like to do? How do you spend your time? What makes you feel good in life? *
Your answer
What drew you to looking into this program? What is/are your primary goals? (Weight loss, strength gain, general fitness, flexibility) *
Your answer
Please also check any goals that apply below: *
Required
What is the ONE thing that you would really like to do, achieve, or avoid if there were NO limits? *
Your answer
Are you currently receiving treatment from any other medical professionals? If so, what? Are you on medications? (If so, please list them and the purpose of the medication.) What is the ultimate goal of the treatment you are receiving? *
Your answer
Are you currently exercising consistently? Are you working with a trainer? If so, please describe your routine. *
Your answer
Are you currently on a diet or special nutrition regimen? If so, please describe. *
Your answer
If not, have you ever been? What did you try before and what caused you to stop? Have you experienced success in the past? What was your main challenge? *
Your answer
Tell us a little about your current nutrition habits (be honest... no judgment; we’re here to help you improve!) What do you typically eat? *
Your answer
Are you taking any nutritional supplements currently? If so, please list: *
Your answer
What are your energy levels like throughout the day? *
Your answer
How many times were you sick last year? *
Your answer
Do you have any additional health or medical concerns that we need to be aware of? *
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms