Only Offering On-Line Services
Filling out this form does not bind you to working with Eat Well Perform Well. It simply begins the process of seeing if Jules and her services are a good match for you and your goals.
Email address *
WAIT-LIST until September 8, 2019
How did you hear about Eat Well Perform Well? *
Required
Name of person/place that recommended my services.
Your answer
Your name (First and Last) *
Your answer
Your mailing address (Street, Town, State & Zip Code)
Your answer
Your Cell Phone (Best Contact #) *
Your answer
Age? *
Your answer
If you are a student athlete- what sport and position do you play?
Your answer
If not a student - what is your occupation? And how many hours a week do you work?
Your answer
Current Weight *
Your answer
Goal weight? (and time frame you would like to accomplish this in?)
Your answer
Height (Feet and Inches) *
Your answer
Body Fat % (if you know it)
Your answer
Only on-line services - wait list until Sept 8, 2019 *
Required
Do you have any health issues Jules needs to be aware of? High blood pressure, depression etc?
Your answer
Do you or have you ever had an eating disorder? (All answers remain confidential) If yes, please explain. If no, type the word ‘no’ and move on.
Your answer
Reason/s for Hiring Jules *
Required
How active are you? Check one *
Required
Water Intake Daily in Ounces - Check One *
Required
Cups of Coffee Per Day *
Required
Energy Drinks *
Required
Juice (grape, apple, grapefruit, orange, etc) *
Required
Alcohol (**I will NOT take clients or athletes who drink more than 3 drinks a week**) *
Required
Do you chew tobacco, smoke or vape? *
Required
Allergic to anything? Please list. *
Required
Who Will Be Grocery Shopping? *
Required
Who Will Be Preparing Your Meals Weekly? *
Required
Fruits you WILL eat? Click box *
Required
Veggies you WILL eat? CHECK BOXES *
Required
Proteins you WILL eat? CHECK BOXES *
Required
Good Fats
I'm a Vegan *
Required
I'm a Vegetarian *
Required
Waiver Release of Liabilities and Responsibilities By checking the yes box below I release all liabilities and responsibilities given to Nutrition by Jules LLC for the construction of this on-line health and fitness training, nutrition, and supplementation program or any contest I am participating in. By checking the yes box of said document, I have consulted with a doctor and or a physician before performing any exercises listed in this training program or executing a nutrition and/or supplementation regimen. I understand that participating in any exercises constructed by Nutrition by Jules LLC that there is an increased risk of injury in which I am fully aware and grant the release of all liabilities and responsibilities if any injury or injuries occur. With my checking of the yes box I acknowledge that there is a “No Refund Policy” or “transfer of plan” to another person for the acquisition of information and intellectual property dispensed by Nutrition by Jules LLC. *
Required
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