Basic Information

How do you prefer me to contact you?

How did you find us?
FacebookBusiness CardWebsiteReferralWalk inMet in Person


Lifestyle Information


How would you describe your occupation activity level?
None (mostly sedentary)Moderate (light activity such as walking)High (heavy labor, very active)

How often do you travel?
RarelyA few times a yearA few times a monthWeekly

Medical and Health Information

Are you experiencing any stresses or motivational problems?

Do you suffer from diabetes, asthma, high or low blood pressure?

Are you a current cigarette smoker?

Your current nutrition plan could be best characterized as.
Low-FatLow-CarbHigh-ProteinVegetarian/VeganNo Special DietNeither



Please rate your readiness for change. (1 being NOT READY, 10 TOTALLY READY)

Which of the following best describes what you want to accomplish? *
Improved general healthImproved enduranceIncreased strengthIncreased muscle massFat lossAthletic PerformanceWeight gain

Expected timeline for achieving your goal.
8 weeks16 weeks24 weeks32 weeks40 weeks1 year> 1 year

Are you currently exercising regularly (at least 3x per week)?

Have you trained with a personal trainer before?

At what times during the day would you prefer to train?

How often do you want to do Personal Training a week?
1 Session2 Sessions3 Sessions4 Sessions5 Sessions6 Sessions7 Sessions

Are you number 1 in your life?

All fields are required.

Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness 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.