Basic Information


How do you prefer me to contact you?
EmailPhoneText

 

What do you want?


In general, what are your goals? Check all that apply.
Lose weight/fatGain weightMaintain weightAdd MuscleImprove physical fitnessLook betterFeel betterHave more energy and vitalityGet control of eating habitsGet strongerPhysique competition / modelingImprove athletic performance



 

What do you expect?




 

What do you want to change?


Have you tried anything in the past to change your habits, your health, your eating, and / or your body? If so, what?
YesNo

Right now, how would you rank your overall eating / nutrition habits? (1 being HORRIBLE - 10 AWESOME)
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Are you regularly active in sports and/or exercise? If so, approximately how many hours per week?
NoFewer than 5 hours5-910-1415-1920 or more

Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
NoFewer than 5 hours5-910-1415-1920 or more



 

What's your health like?


Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
YesNo

Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
YesNo

Right now, are you taking any medications, either over-the-counter or prescription?
YesNo

On a scale of 1-10, how would you rank your health right now? (1 being WORST, 10 AWESOME)
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How is your stress and recovery?


Given all the demands of your life, what is your typical stress level on an average day? (1 NO STRESS - 10 EXTREME STRESS)
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On average, how many hours per night do you sleep?
4 or fewer hours5 hours6 hours7 hours8 hours9 hours10 or more hours



 

How ready, willing, and able are you to change?


Right now, on a scale of 1-10 (1 being NOT AT ALL, 10 COMPLETELY)

How READY are you to change your behaviors and habits? *
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How WILLING are you to change your behaviors and habits?
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How ABLE are you to change your behaviors and habits?
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All fields are required.

Disclaimer
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or personal training consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.