Free Health Evaluation
Ready to finally feel in control of your health again?  Fill out this short form to ge a free, personalized health evaluation - no pressure, no gimmicks.  An Accountable U Fitness Coach will evaluate your responses and reach out to walk you through a custom plan tailored to your goals, lifestyle, and challenges.

Whether your goals are sustainable weight loss, increased energy, maximizing your workouts, or simply just feeling better in your own skin - we'll help you get there with structure, support, and the accountability you've been missing.  

Your success is our number one priority - so let's get fit together!
Sign in to Google to save your progress. Learn more
Email *
Name *
Full Address *
Phone number *
How old are you? *
What is your height? *
What is your current weight? *
What is your ideal goal weight?   *
Approximately how many calories do you consume per day? (If known) *
Have you ever used a food/calorie tracking app?  If so, which one? 
What is your daily activity level? *
Have you tried to lose weight in the past?  If so, what programs or diet plans have you tried?
Do you have any health issues or physical restrictions that we should be aware of? *
What is your attitude towards making simple changes that can positively impact your health for the rest of your life? 

1 = Not confident or willing
2 = Very hesitant, but willing to give it a try
3 = Willing, but I know I'll need a lot of help getting there
4 = Very willing and dedicated
5 = Let's do this! 
 *
Has anything kept you from achieving your weight loss goals in the past?  If so, briefly explain.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms