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WORK WITH ME

ABOUT YOU & YOUR GOALS

Your First Name*

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Your Last Name*

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Preferred Email Address*

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Phone Number

What number should I call you at to have our session? Note: Consults are done by call only. Coaching is done by phone or video conference if desired.

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Where are you located?*

What Timezone, City/State or Country are you in?

I need to know your time zone for scheduling purposes

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How did you find me?*

YouTube

Facebook

Instagram

Family/Friend

Google Search

What's your height?*

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How old are you?*

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What's your current weight?*

in pounds, kg or stones (please indicate which you're using)

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What's your goal weight?*

in pounds, kg or stones (please indicate which you're using)

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What are your Goal(s)?*

To Lose Fat

To Build Muscle (Tighten, Tone, Build Mass and/or Strength)

To get Healthy & Heal Physically

To feel More Energized & Happy Mentally

I need help with Exercise & Workouts

I want a meal plan & nutrition advice

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MEDICAL & HEALTH HISTORY

Do you have any food or seasonal allergies?*

Please list all foods and things you're allergic to. If you don't have allergies, please type N/A.

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Are you currently taking any medications including birth control and all over-the-counter medications?*

Please list the medication name and frequency of use (daily, weekly). Include every pill you swallow for health.

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Are you currently taking any supplements?*

If so please list the name and brand. Include everything you take for fitness including things for energy, recovery and/or appetite suppressants. If not, type N/A.

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Do you have any injuries, illnesses or medical conditions that affect your ability to eat or exercise?*

If so, please list them below.

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Have you ever been hospitalized or had surgery?*

If so, please list when and why. If not, please type N/A.

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Are you pregnant or breastfeeding?*

I'm pregnant

I'm breastfeeding

I'm not pregnant or breastfeeding (also see: I'm male)

I'm not pregnant but I have kids

I'm not pregnant but I want to be (actively trying/in next few years)

I'm struggling reproductively (miscarriage, erectile dysfunction, low/no libido)

I'm pre-menopause, in menopause, or post-menopause

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HABITS AND HISTORY

How does your weight compare to other people with the same height and size as you?*

I weigh less than everyone else

I tend to weigh more (10+ pounds/2-3 kgs.)

My weight is the same, give or take a few lbs./kgs.

How do carbs affect your weight?*

(fruit, bread, pasta, cereal, etc.)

I could eat carbs 24/7 and don't gain weight

Carbohydrates don't affect my weight

I gain weight quickly when I eat carbs

How would you describe your energy levels?*

(without coffee, caffeinated teas, or energy drinks)

I have naturally high energy and I move nonstop

I feel tired often and struggle to get motivated

It fluctuates up and down

What best describes your hunger when you wake up?*

I crave carbs and coffee almost immediately

I feel hungry within an hour of waking up

I don't feel hungry and often skip breakfast

How often do you get more than 6 solid hours of sleep a night?*

Days per week

0 days

1-2 day

3-4 day

How often do you feel stressed or anxious?*

Days per week

Never

1-2 days

3-4 days

How many days a week do you workout?*

1-2

3-4

6-7

Do you have any of the following?*

Please check everything that you experience on a regular basis.

I struggle with cravings (sugar, carbs, dairy, alcohol, etc.)

Dry skin

Premature aging

Acne on your face and/or body

Rashes

Post nasal drip or sinus issues

Thinning Hair

Constipation

When I go #2 it looks like marbles

Bloat and water retention

Heartburn

Stiff, sore muscles

Joint pain

Ringing ears

Is there anything else, you need me to know?

Dietary restrictions/preferences, foods you won't/can't eat, deal-breakers, or specific training goals?

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About your Application*

Your information will be used to assess if you’re a candidate for coaching and consulting only. Your information will never be used for any other purpose or shared with anyone for any reason. By submitting this form you’re aware of the Privacy Policy and acknowledge that it’s ok to email you about coaching and consulting services requested.

Yes! I'm aware of the Privacy Policy and it's ok to email me about the next steps

Woohoo!

Thanks for filling out the form! This helps make our session(s) much more effective!

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