New client intake form
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)
Address (Street, Town, State & Zip Code)
Cell Phone (Best Contact #)
Occupation/In School? - Please briefly describe
Sport and position if applicable to you OR if you are personally training for an event.
Which location works best for you?
Danvers, MA North Shore Performance Training Rt 1 N
Woburn, MA TradeCenter Suite 5900 Exit 35
Foxboro, MA Mass Premiere Courts - Green Street
Zelos Athletics in Westbourgh, MA
I am not local and need to work via Facetime, email and text
Goal Weight (Time frame you have in mind to attain goal?)
Height (Feet and Inches)
Body Fat % (if you know it)
Eat Well Perform Well Programs - Choose 1
4-week custom nutrition plan/counseling $340
6-week custom nutrition plan/counseling $510
10-week custom nutrition plan/counseling $749
12-week custom nutrition plan/counseling - $840
6-week ONLINE weight loss program $199
$30/30 minutes body composition appointment
45 minute 1:1 office visit $65 (body comp taken, macros given based on goal & sample meal plan emailed - follow-ups $30/30 minute
Phone Consult - $60 30 minutes, plus a fueling packet or lifestyle packet emailed - follow-ups $30/30 minute
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.
If you answered yes to the above question, please describe your eating disorder in a few sentences.
Any health issues you are currently dealing with? Any injuries you are dealing with? If yes, please describe in detail.
Please list ALL supplements & medications you take - prescribed and over the counter (this will be kept private)
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
I'm Training for an Event (marathon, 5K, Tough Mudder, triathalon, etc)
I Have a Special Occasion Coming Up (Wedding, Class Reunion, Vacation)
I Want to Know My Body Fat/Muscle Ratios
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 (**alcohol directly impacts performance and ability to change body composition)
1-3 per week
4-7 per week
more than 8 a week
I’d like to talk more about this privately with you.
Do you chew tobacco, smoke or vape?
Allergic to any foods? Please list
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?
Veggies you WILL eat?
Proteins you WILL eat?
lean ground beef or chicken
yellow fish tuna
top round london
t-bone short loin
I'm a Vegan
I'm a Vegetarian
How did you hear about Eat Well Perform Well
Found you through the internet
Friend recommeded you
I came to a seminar of yours
A family member of mine used your services
North Shore Performance Training Facility recommended you
Zelos Athletics Facility recommended you
High Function Fitness recommended you
Dan Boothby recommended you
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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