Health Assessment Form
Hi there!  I am anxious to work with you and help you begin to commit to better exercise and nutrition habits. Before we get started, I think it is a great time for you to let me know about where you stand from a wellness perspective and what goals you have for yourself. The reponses to this survery are confidential and are only for my use.

Please keep in mind that you should consult with your doctor before beginning any new lifestyle changes to ensure you are well enough to participate.

Beachbody requires that we remind all of you that these products are not intended to diagnose, treat, cure, or prevent any disease. I will say that it has changed my life for the better as well as many of my clients. I am looking forward to you being my next client success story.

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Email *
Client Name *
Username on the preferred platform I contact you - (EX: @sarahelizabeth27 on Instagram) *
Where are you from? Groups are only open to those in the USA, UK, Canada and France. *
How did you learn about this opportunity? *
Coach Name *
Age/ Height/ Current Weight *
Phone number *
Gender *
What do you believe is your ideal weight or goal weight? *
Do you currently exercise? *
Please describe what your current goals are for yourself from an exercise and nutrition standpoint. *
Please provide a brief history of any past medical conditions you would like for me to be aware of if any. *
Do you have any food allergies or intolerances? If you answered yes please describe. *
Do you currently take any vitamins or supplements? If you answered yes please list them below. *
Are your currently taking any medication? If you answered yes please list them below. *
How do you personally view your health or current habits? *
What would you like to change/ improve by starting this challenge? *
In the event that you seem to lose motivation or get off track. How would you like for me to approach you and remind you of your goals that you had when you started? *
Do you currently have a Beachbody On Demand Membership Subscription?
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Are you currently using Shakeology or any other Beachbody products?
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Are you already getting the 25% discount on Beachbodyproducts?
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Is there anything else that you would like for me to know about you? *
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