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.
WAIT-LIST until September 8, 2019
How did you hear about Eat Well Perform Well?
Found you through the internet
Someone I know recommended you - please list name below
I came to a seminar of yours
Name of person/place that recommended my services.
Your name (First and Last)
Your mailing address (Street, Town, State & Zip Code)
Your Cell Phone (Best Contact #)
If you are a student athlete- what sport and position do you play?
If not a student - what is your occupation? And how many hours a week do you work?
Goal weight? (and time frame you would like to accomplish this in?)
Height (Feet and Inches)
Body Fat % (if you know it)
Only on-line services - wait list until Sept 8, 2019
4-week nutrition plan/counseling $320
6-week nutrition plan/counseling $450
10-week nutrition plan/counseling $700
Recipe booklet & healthy living packet OR fueling packet for athletes- one time purchase $139
Do you have any health issues Jules needs to be aware of? High blood pressure, depression etc?
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.
Reason/s for Hiring Jules
Reduce Body Fat
My Coach wants me Bigger and Stronger
Heal from an Injury
Increase Energy Levels in Everyday Life & Training
I'm new to working out and want to eat better while doing so
Training — (marathon, 5K, Tough Mudder, triathalon, etc)
I Have a Special Occasion Coming Up (Wedding, Class Reunion, Vacation)
How active are you? Check one
Sedentary -Llittle to no exercise/desk job
Lightly Active - Light exercise/sports 1-3 days/week
Moderately Active - Moderate exercise/sports 3-5 days/week
Very Active - Heavy exercise/sports 6-7 days/week
Extremely Active - Very heavy exercise/physical job/train 2x a day
I'm injured - and can't workout right now
Water Intake Daily in Ounces - Check One
less than 16oz daily
More than a gallon daily
Cups of Coffee Per Day
More than 3 cups
Juice (grape, apple, grapefruit, orange, etc)
Alcohol (**I will NOT take clients or athletes who drink more than 3 drinks a week**)
1-3 per week
4-7 per week
8-12 per week
12+ per week
I’d like to talk more about this privately with you.
Do you chew tobacco, smoke or vape?
Allergic to anything? Please list.
Yes (if yes, please list below what you are allergic to and the effects.
Who Will Be Grocery Shopping?
Food Delivery Service
Who Will Be Preparing Your Meals Weekly?
Meal Delivery Service (with Jules guidance)
Fruits you WILL eat? Click box
Veggies you WILL eat? CHECK BOXES
Proteins you WILL eat? CHECK BOXES
lean ground beef or chicken
yellow fish tuna
top round london
t-bone short loin
Pumpkin seed oil
Flaxseed - ground
I'm a Vegan
I'm a Vegetarian
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.
YES I am agreeing to the above waiver statement
Send me a copy of my responses.
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