Accountable U Fitness - Free Health Evaluation

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Accountable U Fitness offers simple and effective weight loss programs that allow you to eat most of the foods you already enjoy. With our programs, there are no expensive meal plans to purchase or crazy food restrictions. Getting started is as simple as a trip to the grocery store and a conversation with your Coach (with a whole lot of tips and tricks along the way!) By following our programs and participating in weekly check-in's with your Coach, we are confident you will reach your weight loss goals. YOUR SUCCESS IS OUR NUMBER ONE PRIORITY! To better understand your fitness goals, please complete the following questionnaire to help us determine if we are a good fit! A Coach will contact within the next day you to discuss a customized plan and answer all of your questions you may have about our programs. We look forward to helping you meet your weight loss and fitness goals!

Email *

Name *

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? *

Very Active (e.g., Weight training 2-4 times per week, 30 minutes of cardio daily)

Moderately Active (e.g., Weight training 1-2 times per week, 1-3 days of cardio)

Lightly Active (e.g., Light walking daily)

Sedimentary (e.g., Very little walking or weight training)

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.

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