New client intake form
Email address *
Please fill out completely and submit to Jules Hindman via hitting the send button at the end. ALL info is kept confidential. I will email/call OR text you to schedule an appointment or a phone consult. A PayPal invoice will be emailed separately for services.
Name (First and Last) *
Your answer
Address (Street, Town, State & Zip Code) *
Your answer
Cell Phone (Best Contact #) *
Your answer
Age? *
Your answer
Occupation/In School? - Please briefly describe *
Your answer
Sport and position if applicable to you OR if you are personally training for an event.
Your answer
Which location works best for you? *
Current Weight *
Your answer
Goal Weight (Time frame you have in mind to attain goal?) *
Your answer
Height (Feet and Inches) *
Your answer
Body Fat % (if you know it)
Your answer
Eat Well Perform Well Programs - Choose 1 *
Have you had a physical in the last 6 months? *
Do you or have you ever had an eating disorder? (All answers remain confidential) If yes, please explain. *
Required
If you answered yes to the above question, please describe your eating disorder in a few sentences.
Your answer
Any health issues you are currently dealing with? Any injuries you are dealing with? If yes, please describe in detail.
Your answer
Please list ALL supplements & medications you take - prescribed and over the counter (this will be kept private)
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 (**alcohol directly impacts performance and ability to change body composition) *
Required
Do you chew tobacco, smoke or vape? *
Allergic to any foods? Please list *
Your answer
Who Will Be Grocery Shopping? *
Who Will Be Preparing Your Meals Weekly? *
Fruits you WILL eat? *
Required
Veggies you WILL eat? *
Required
Proteins you WILL eat? *
Required
I'm a Vegan *
I'm a Vegetarian *
How did you hear about Eat Well Perform Well *
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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