Optimal Performance Program Application
Full Name *
Your answer
Phone Number *
Your answer
Age *
Your answer
What is your occupation? *
Your answer
What are your work hours? *
Your answer
How many days per week realistically are you able to work out? *
On a scale of 1-10, with 10 being the most ready, how ready are you to make this transformation? *
I'm thinking about it
I WANT this!
What is your major motivation behind wanting to get healthy and make this transformation? *
Your answer
Is your spouse or significant other supportive of this transformation? *
Has your doctor mentioned if you have any specific conditions or health risks? *
If you answered yes to the question above, what conditions may limit your ability to perform certain exercises or work out on a regular basis? *
Place N/A if not applicable
Your answer
Are you currently on any medications? *
If you answered yes to the question above, please list your medications below. *
Place N/A if not applicable
Your answer
How much do you spend on medications and doctor visits each month? *
Do you feel like you spend too much time in your doctor's office each quarter?
Are you satisfied with your current insurance deductible?
Have you ever invested in your health in order to help you reach your goals? *
If so, please describe the program and your overall results? *
Your answer
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