Client Application
Email address *
First and Last name. *
Phone *
How do you want me to contact you? *
Address *
Birthday *
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Emergency Contact Name and Phone *
Do you want to see changes in your body weight and/or composition? If yes please describe the changes you want to see. *
Have you been successful with exercise and nutrition in the past (even just a little bit)? If yes what worked for you? *
What do you consider to be the biggest obstacles in eating healthier meals (no time, cravings, stress eating, money, cooking skills, etc.)? *
Where in your life are these obstacles to better nutrition not happening? Are there times when things are better? *
What do you consider to be the greatest obstacles in achieving your fitness goals? (time, accountability, unsure of what to do, negative experiences, joint/physical pain, etc.) List any other concerns you have. *
Where in your life are these obstacles to exercise not happening? Are there times when things are better? *
What do you want exercise and nutrition to do for you? Select all that apply. *
Required
Do you have any other fitness and/or health goals? *
What types of exercise/physical activities interest you? *
Are there any other health or lifestyle habits you want to change? *
Do you have any medical/health conditions? If yes please list. *
Are you taking any prescription medication? If yes, what medications and why? *
Do you take any over-the-counter medication? If yes, what medications and why? *
Do you take any vitamin, mineral, or herbal supplements? If yes please list. *
What is your job/work lifestyle like? (sitting at a desk, retail, labor, childcare, stay at home etc.) *
How much sleep do you get each night on average? *
What is the most important thing I can do to help you? *
A copy of your responses will be emailed to the address you provided.
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