THIS IS IT
A BIG STEP
TOWARDS YOUR GOALS

Starting can be overwhelming and scary, but let me assure you, we will work as a team and conquer TOGETHER.

In order to get started on the right path, I ask that you fill out the consultation questionnaire below. Your time is precious, as well as mine. When filling out the questionnaire, please be honest and thorough with your responses, to ensure that I can get to know you, your history, your goals, and how I can help you along your journey.

First Name

Email Address

Last Name

Date of Birth

Phone

Preferred way of contact

Phone

Text

In general, what are your goals? Check all that apply.

Lose weight/fat

Gain weight

Maintain weight

Add muscle

Improve overall health

Improve physical fitness

Look better

Feel better

Have more energy and vitality

Healthy aging

Gain control of habits

Get stronger

Physique competition/modeling

Improve athletic performance

Training for an athletic event

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

Considering your current eating habits/diet and goals, what obstacles are getting in the way? Check all that apply.

Feeling unsure about what to eat

Feeling unsure about how much to eat

Lack of meal planning or prepping

Lack of time to cook

Not feeling confident about how to prep or cook foods

Drinking too much alcohol

Struggling with impulses/cravings around foods

Emotional eating/stress eating

Eating when I'm not hungry

Eating until I'm overfull or stuffed

Eating too quickly

Feeling unsatisfied by food and always hungry

Not feeling hungry

Obsessive or anxious about food

Feeling guilty/shame related to eating

Peer pressure to eat or not eat a certain way

Lack of access to healthier food

Easy access to trigger food/irresistible food

What is your preferred eating style?

I'll eat mostly anything (no preference or restrictions)

Mediterranean (emphasizes plant foods, healthy fats, and moderate amounts of lean protein)

Paleo

Ketogenic

Vegetarian

Fully plant based

Do you have a nutrient balance preference?

Balanced/no preference

Low-carb, high-fat

High-carb, low-fat

Are there any foods that your intolerent or sensitive to?

Yes

If you answered yes, please elaborate:

How do you rate the overall quality of your food choices?

Low quality (prepackaged/processed)

High quality (fresh or frozen foods)

A mix of both low quality and high quality

How much water do you drink per day (e.g. 5 cups, 120 oz)?

How many meals do you typically eat per day?

Are you taking any nutritional supplements, if so what (e.g. multivitamins, fish oil, protein, etc.)?

What best describes your current weekly workouts? This is time spent purposefully exercising.

Very light. Almost no purposeful exercising.

Light. 1-3 hours of easy to moderate exercise.

Moderate. 3-4 hours of moderate exercise.

Intense. 4-6 hours of strenuous exercise.

Very intense. 7+ hours of strenuous exercise.

Not including your weekly workouts, how active are you each day?

Very light. Sitting most of the day (e.g. desk job, student, etc.)

Light. Mix of sitting, standing, and lightly active. (e.g. teacher)

Moderate. Continuous easy to moderate activity (e.g. restaurant server).

Heavy. Strenuous activity all day (e.g. construction worker)

Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any, please elaborate

Why do you want to workout with a coach? What do you expect from a coach?

Any other additional comments?

What days and times work best for a scheduled call?

First Name

Email Address

Last Name

Date of Birth

Phone

Preferred way of contact

Phone

Text

In general, what are your goals? Check all that apply.

Lose weight/fat

Gain weight

Maintain weight

Add muscle

Improve overall health

Improve physical fitness

Look better

Feel better

Have more energy and vitality

Healthy aging

Gain control of habits

Get stronger

Physique competition/modeling

Improve athletic performance

Training for an athletic event

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

Considering your current eating habits/diet and goals, what obstacles are getting in the way? Check all that apply.

Feeling unsure about what to eat

Feeling unsure about how much to eat

Lack of meal planning or prepping

Lack of time to cook

Not feeling confident about how to prep or cook foods

Drinking too much alcohol

Struggling with impulses/cravings around foods

Emotional eating/stress eating

Eating when I'm not hungry

Eating until I'm overfull or stuffed

Eating too quickly

Feeling unsatisfied by food and always hungry

Not feeling hungry

Obsessive or anxious about food

Feeling guilty/shame related to eating

Peer pressure to eat or not eat a certain way

Lack of access to healthier food

Easy access to trigger food/irresistible food

What is your preferred eating style?

I'll eat mostly anything (no preference or restrictions)

Mediterranean (emphasizes plant foods, healthy fats, and moderate amounts of lean protein)

Paleo

Ketogenic

Vegetarian

Fully plant based

Do you have a nutrient balance preference?

Balanced/no preference

Low-carb, high-fat

High-carb, low-fat

Are there any foods that your intolerent or sensitive to?

Yes

If you answered yes, please elaborate:

How do you rate the overall quality of your food choices?

Low quality (prepackaged/processed)

High quality (fresh or frozen foods)

A mix of both low quality and high quality

How much water do you drink per day (e.g. 5 cups, 120 oz)?

How many meals do you typically eat per day?

Are you taking any nutritional supplements, if so what (e.g. multivitamins, fish oil, protein, etc.)?

What best describes your current weekly workouts? This is time spent purposefully exercising.

Very light. Almost no purposeful exercising.

Light. 1-3 hours of easy to moderate exercise.

Moderate. 3-4 hours of moderate exercise.

Intense. 4-6 hours of strenuous exercise.

Very intense. 7+ hours of strenuous exercise.

Not including your weekly workouts, how active are you each day?

Very light. Sitting most of the day (e.g. desk job, student, etc.)

Light. Mix of sitting, standing, and lightly active. (e.g. teacher)

Moderate. Continuous easy to moderate activity (e.g. restaurant server).

Heavy. Strenuous activity all day (e.g. construction worker)

Where would you like your weekly workouts to be?

Very light

Light

Moderate. 3-4 hours of exercise.

Intense. 4-6 hours of exercise.

Very intense. 7+ hours of exercise.

Considering your current movement and exercise routine, what obstacles apply to you? Check all that apply.

Feeling unsure about what to do

Feeling uncomfortable about how well I move

Feeling uncomfortable working out

Lack of place where I feel comfortable working out

Lack of people I feel comfortable working out with

Lack of time to move more

Lack of energy to move more

Lack of motivation/understanding the importance to move more

Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any, please elaborate

Why do you want to workout with a coach? What do you expect from a coach?

Any other additional comments?

What days and times work best for a scheduled call?

CULTURE
fitness and nutrition

THIS IS IT
A BIG STEP
TOWARDS YOUR GOALS

BACK TO TOP

THIS IS IT A BIG STEP TOWARDS YOUR GOALS

THIS IS IT
A BIG STEP
TOWARDS YOUR GOALS