Please, Tell Me A Little About You
There’s a story we all tell ourselves about who we are and what we’re capable of. My training style and philosophy will help you reconsider / rewrite your self story. It’ll help open the door to changing your body and boosting your confidence.

"Change your eating, your body, and your health from the inside out.” I talk about the “ working in” thing a lot when explaining what sets my coaching apart from other programs that claim to help you get fit. You see, inner change — exploring and shifting how you think about your life, your body, and who you are — is necessary to make lasting outer change.

Even learning / grooving the basics: what to eat, how much to eat, and when to eat requires you to change how you think, plan, and strategize, at least a little.

Change your insides, change your outsides.

Lets get started below.
Sign in to Google to save your progress. Learn more
Email *
Date *
What is Your First and Last Name? *
Phone number *
Gender M/F/Other *
Age *
 Where do you live, city and state? (its not shared publicly) *
What has you interested in working with me today? *
In Your Own Words, Why Are You Interested In The Above Program You Elected? Write as much as you possibly can please. *
What is Your Chief or Biggest Complaint When It Comes to Your Health or Fitness? *
Are you member at a gym? *
How did you first hear about me and my company The Wellness CSI *
Overall, how happy are you right now with your current health, nutrition, and/or fitness choices? *
Which Options BEST Describes Your Current  Situation? (you can choose more than one) *
What's something that would make you feel happier about your choices? (Choose all that apply.) *
What do you think is your biggest hurdle to changing how you look and feel? *
How important do you think it is to have someone monitor your progress, keep you accountable, and help you stay consistent? *
Very Important
Not Important
General Eating Patterns: As best as you can remember right now, tell me generally about an average day of eating and drinking? Please Include Time of Day and What you might normally eat and drink?
Right now, are you following any particular diet or style of eating?
If yes, what? And for how long have you followed this way of eating?
On a Scale of 1-10 , how consistent would you say you are with your eating habits?
ALL Over The Place
Perfectly Consistent
Clear selection
If you are less consistent than you'd like to be, what seems to get in the way or knock you off your tracks?
Do you have any issues with
Clear selection
Tell my a bit more about your answers above. How long? When? What have you tried that hasn't worked?
How often do you have a bowel movement each day?
Clear selection
Do you feel like you have trouble controlling your appetite / hunger?
Never Hungry
Always Famished Get Me Some Food!
Clear selection
Do you feel like you have trouble controlling your appetite ? hunger?
Clear selection
Have you ever noticed any connection between stress and your eating habits? If yes, what happens? Like "when I'm stress I eat more /less  of...
If yes sometimes what do you normally crave? And what do you normally do when you have cravings?
We Will Talk About Your Daily Habits and Environment like. How often do you eat out, make meals at home, how often do you shop, do you like cooking? When we speak.
Your Goals and Priorities! Thinking about all that you have written down so far, what do you think you might like to start working on or addressing first?
Right now: Do you have someone in your life who makes sure you're accountable and consistent when it comes to your health, nutrition, and/or fitness choices? *
Where do you feel like you need the most help with regarding your health, nutrition, and fitness? (Choose all that apply.) *
If you could make ONE very small improvement to your health, nutrition, and/or fitness choices right now, what might it be? *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy