Full Name
*
Email
*
Date of birth
What type of guidance are you looking for?
Fitness Coaching
Nutrition Habit Coaching
Both Fitness and Nutrition Coaching
A Personalized workout plan to do on your own without on-going coaching
What is the most important General Goal for you right now?
Improved Health
Improved Endurance
Increased Power
Increased Strength
Increased Muscle Mass
Fat Loss
Weight Gain
Sport Specific
Which is of greater importance to you?
*
Immediate Progress that is less easily maintained
Maintainable Progress that may not be as rapid
Do you have any medical conditions that would effect your participation in physical activity?
*
Yes
Yes, but cleared by doctor to participate with or without limitations
No
How confident are you that you can make improvements in your habits to get to your goal?
1 (Low)
2
3 (Moderate)
4
5 (High)
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To what degree do you perceive your environment as stressful?
Minimal
Moderate
Average
Extremely
What is your activity level for an average day?
Seated Most of the day, No Exercise
On feet some, Exercise 1-2 days a week
On feet half of the day, Exercise 2-5 days a week
On feet all day plus exercise 4-6 days a week
Athlete or hard laborer, Exercise 6-7 days a week
