check

Application

Tell me more about yourself. By learning more about you, I can better care for you and make sure coaching fits your needs.

Click the button below to start.

Start

Question 1 of 43

Name

Question 2 of 43

Date of birth

Question 3 of 43

Gender

A

Male

B

Female

C

Prefer not to say

D

Other

Question 4 of 43

Mobile phone

Question 5 of 43

Address

Question 6 of 43

Emergency Contact Name, Number

Question 7 of 43

What are your goals?

(Select all that apply)
A

Lose fat

B

Gain muscle

C

Maintain weight

D

Improve physical fitness

E

Look better

F

Feel Better

G

Have more energy and vitality

H

Get control of eating habits

I

Get stronger

J

Physique competition/modeling

K

Improve athletic performance

L

Other

Question 8 of 43

List all of your concerns about your health, eating habits, fitness, and body.

Question 9 of 43

Out of the above concerns, which ones feel the most urgent to you? 

Question 10 of 43

Why?

Question 11 of 43

What do you expect from me as a coach?

Question 12 of 43

What are you prepared to do to work towards your goals? 

Question 13 of 43

Have you tried anything in the past to change your habits, health, eating, or body?

A

Yes

B

No

Question 14 of 43

If so, what did you try?

Question 15 of 43

Which of those things worked well for you? What did not?

Question 16 of 43

How, specifically would you like your habits, your health, your eating, or your body to be different?

Question 17 of 43

If you were to consider making further changes to your habits, health, eating, or body, what might those be?

Question 18 of 43

Have you already changed your habits, your health, your eating, or your body recently?

A

Yes

B

No

Question 19 of 43

If so, what?

Question 20 of 43

If you were to consider making further changes to your habits, your health, your eating, or your body, what might those be?

Question 21 of 43

Right now how would you rank your overall eating / nutrition habits?

(Select all that apply)
A

1 - Horrible

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 - Awesome!

Question 22 of 43

Why did you rate yourself that way?

Question 23 of 43

Are you regularly active in sport or exercise?

A

Yes

B

No

Question 24 of 43

If so, how many hours per week?

A

Less than 5 hours

B

5-9 hours

C

10 -14 hours

D

15 - 19 hours

E

20 + hours

Question 25 of 43

What other types of movement and activities do you do?

Question 26 of 43

Who lives with you? Check all that apply.

(Select all that apply)
A

Spouse or partner(s)

B

Roommate(s)

C

Child(ren)

D

Pet(s)

E

Other Family

F

Other

Question 27 of 43

Do you have children? If yes, how many and what are their ages?

Question 28 of 43

Who does most of the grocery shopping in your household? Check all that apply.

(Select all that apply)
A

Me

B

Spouse or partner(s)

C

Roommate(s)

D

Child(ren)

E

Other

Question 29 of 43

Who decides most of the menus/ meal types in your household? Check all that apply.

(Select all that apply)
A

Me

B

Spouse or partner(s)

C

Roommate(s)

D

Child(ren)

E

Other

Question 30 of 43

Right now, how much do the people and things around you support health, fitness, and / or behavior change?

A

1 - Not at all

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 - Completely

Question 31 of 43

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

A

Yes

B

No

Question 32 of 43

Do you have any health concerns such as illness, pain, or injuries right now?

A

Yes

B

No

Question 33 of 43

Are you taking any medications, either over-the-counter or prescription?

A

Yes

B

No

Question 34 of 43

On a scale of 1 to 10 how do you feel about your schedule, time use, and overall busy-ness?

A

1 - My life is panicked and insane

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 - My life is perfectly calm and relaxed

Question 35 of 43

Given the demands of your life, what is your typical stress level on an average day?

A

1 - No stress

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 - Extreme

Question 36 of 43

On average, how many hours per night do you sleep?

A

4 or fewer

B

5 hours

C

6 hours

D

7 hours

E

8 hours

F

9 hours

G

10 or more hours

Question 37 of 43

How do you usually cope with your stress?

Question 38 of 43

How READY are you to change your behaviors and habits?

A

1 - Not at all

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 - Completely

Question 39 of 43

How WILLING are you to change your behaviors and habits?

A

1 - Not at all

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 - Completely

Question 40 of 43

How ABLE are you to change your behaviors and habits?

A

1 - Not at all

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10 - Completely

Question 41 of 43

Where did you hear about us? 

Question 42 of 43

DISCLAIMER

By checking the box, you recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and fitness consultation. 

 

Any information provided is not to be followed without prior approval from your doctor. If you choose to use this information without such consent, you agree to accept full responsibility for your decision. 

A

Agree

Question 43 of 43

Please enter your initials

Confirm and Submit