A1 Fit Coaching Application Form

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Please fill out the form below and be detailed. The more I understand about you the better!

Name *

Email *

Phone ( Country code is +01 for USA) *

Biological Sex *

What kind of program(s) are you interested in? *

What do you currently struggle with the most, and how do you think I can help you with this? * This can be things like your exercise, nutrition, accountability, or Fibromyalgia management, low back pain, core weakness, ect. *

What is the primary goal you'd like to achieve in the next 6 months? *

What obstacles do you foresee that may hinder you from achieving the goal?

How would you describe you training experience: *

What is your current occupation? Does it require extended periods of sitting? *

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes

Do you feel pain in your chest when you perform physical activity? *

Yes

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes

Do you know of any other reason why you should not engage in physical activity? *

Yes

Have you ever had any injuries, surgeries or chronic pain? Please list all injuries or surgeries from the last 10 years, and any chronic pain. Write n/a if not applicable. *

What medications are you currently taking? Please include prescription and OTC medications. Write n/a if not applicable. *

Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? If YES, please explain. Write n/a if not applicable. *

Depending on the package/program you select, pricing will vary but generally expect to budget about $300/month for 1 on 1 Coaching. Group programs are also available at a lower price point. On average, most clients are with me for 9 months. How much are you willing to invest to reach your goals? *

<$100/m

$100-200/m

$200-300/m

$300-400/m

How did you hear about A1 Fit Coaching? *

YouTube

Ascent PT

Client Referral

Other:

If you selected Client Referral or Other, please elaborate below

When are you ready to start?

Anything else you want to share with me?

Submit

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