Client Application
Email address *
Name *
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Email *
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Phone *
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Address *
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Birthday *
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Emergency Contact Name and Phone *
Your answer
Height *
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Weight *
Your answer
Do you have any cardiovascular conditions? If yes please list. *
Your answer
Do you have any other medical conditions? If yes please list. *
Your answer
Are you taking any prescription medications? If yes please list. *
Your answer
Are you taking any supplements? If yes please list. *
Your answer
On a Scale of 1-10, what is your average stress level on a daily basis? *
no stress
extreme stress
What are your top 3 sources of stress? *
Your answer
What is your job/work lifestyle like? (sitting at a desk, retail, labor, childcare etc.) *
Your answer
Does your job require a lot of travel? *
Your answer
Would you describe your life as more sedentary or active? *
Your answer
How Many hours a day do you watch T.V./are on the computer (in your free time)? *
Your answer
What are your hobbies? *
Your answer
How much sleep do you get each night on average? *
Your answer
What types of food do you normally eat? *
Your answer
How many times throughout the day do you eat? *
Your answer
What activities do you engage in while eating? (t.v., computer, reading) *
Your answer
How much water do you drink daily? *
Your answer
Do you prepare most of your meals at home? If yes do you or someone else prepare them? *
Your answer
How often do you go out to eat? What type of food do you normally eat? *
Your answer
Have you ever tracked your food? If yes how did you track your food and was it successful? *
Your answer
Do you smoke? *
Your answer
Do you drink? If yes how often? *
Your answer
What are your short term goals? *
Your answer
What are your long term goals? *
Your answer
What are the top 3 priorities in your life? *
Your answer
What obstacles are preventing you from achieving your goals? *
Your answer
Are you happy with the way your body feels and looks? *
Your answer
Do you have a support system to help you reach your goals? *
Your answer
Have you tried anything else to reach your goals? If so, what was it and what was the result? *
Your answer
What was/is your most recent exercise routine? *
Your answer
Is there a type of exercise you like? *
Your answer
Is there a type of exercise you strongly dislike? *
Your answer
Is there a type of exercise you haven't tried yet but are interested in learning about? *
Your answer
How much time can you devote to your exercise routine each week? *
Your answer
How much time would you like to work with me directly each week? *
Your answer
Does your budget affect your ability to devote as much time and effort and you would like to your goals? *
Your answer
Why do you want to work with me? *
Your answer
What is the most important thing I can do to help you? *
Your answer
A copy of your responses will be emailed to the address you provided.
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