Success Strategy Session Questionnaire
Please fill this questionnaire out completely and honestly so that we can recommend the best way for you to get started on your health & fitness journey. Our goal is to help you confidently decide if our Coaching and programs are a good fit for you!

** Please be sure to click the "SUBMIT" button at the bottom of the form to record and save your responses **
Email *
First & Last Name *
Phone *
Your Age *
Gender *
Your height *
Your current weight *
On a scale of 1 - 10 how would you rank your health and wellness right now? *
Seriously concerned
Feeling great!
Tell us a little bit about your life. Do you have kids? Married? Work? Give us a peek into your day-to-day so we know how we can best fit fitness & nutrition into your schedule. *
Why do you want to work with ExecLevel Wellness as your Coaches? *
Tell us about your specific health, fitness and weight loss goals. *
What methods have you already tried? What's working? What's not? *
How long have you been trying to lose weight or gain control of your health? *
Is nutrition a strength or a weakness? Please provide details - what does a "normal" day of eating look like for you? *
Do you struggle with overeating, malnutrition, cravings and / or binging? If so, tell us about that. *
If you decided to do nothing, how will your current lifestyle affect you in the next year? Next 10 years? *
Does your current weight / body image affect your relationships? How? *
Do you have any injuries? If so, please explain any limitations. *
Are there any kinds of fitness that you really enjoy? Despise? *
When you look in the mirror, describe what you see and how you feel. *
What do you want to see and feel? *
On a scale of 1 - 10, how motivated are you to make a change today? *
Meh, not sure
Let's DO THIS!
Why is your health a financial priority now? *
If you were in your ideal body today, how would you be living your life differently? *
What are you prepared to do to work towards your goals? What areas are you ready to focus on? Check all that apply. *
What else would you like us to know about you? *
How would you like to discuss this questionnaire and path forward? Please specify who you would prefer to chat with (Amy or Randy). *
ExecLevel Wellness Fitness / Nutrition Coaching is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Randall & Amy Nelson are not medical professionals, and your participation in any activity suggested during your Success Strategy Session should always be cleared by a medical professional. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Any involvement in personal fitness training, exercise testing and physical exercise, including the activities suggested by ExecLevel Wellness, can be strenuous and carry a significant risk of damage to property, personal injury, illness, or death. These risks increase for those people in poor health or with known or unknown pre-existing mental or physical conditions. If you choose to participate in these risks, you participate of your own free will and at your own risk. You voluntarily assume all risks associated with such activities.

Always obtain a physical examination from a doctor before starting any physical exercise activity, nutrition plan or supplement. You assume all risk if you fail to do so. In consultation with your doctor, you acknowledge and agree that any recommendations for changes in nutrition, including the use of supplements, or a weight loss program are entirely your responsibility.

Do not disregard professional medical advice or delay in seeking it because of something you have read in our social media groups, web-site, e-mails, posts, webinars, videos or any other content provided by ExecLevel Wellness. Reliance on any information provided by ExecLevel Wellness LLC is solely at your own risk.

You acknowledge and agree that you are voluntarily participating in a program of physical exercise and nutrition under the direction of ExecLevel Wellness LLC. In consideration of ExecLevel Wellness’s agreement to provide this program, you hereby here and forever release, discharge, hold harmless and free from any and all liability Randall & Amy Nelson, ExecLevel Wellness LLC, its owners, agents, employees, contractors, successors, heirs and assigns from any and all claims, demands, damages, rights of action, present or future, out of or connected with any participation in this program including, without limitation, personal or real property damage, injury, illness, or death, as well as all attorney fees and costs incurred by you or caused by third parties to you, arising out of the fitness plan and programs discussed on this website.
A copy of your responses will be emailed to the address you provided.
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