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New Client Application
Please fill out this application honestly and completely. We use this information to determine how best to help you reach your goals.
Step 1 of 6 - Contact Information
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Name
*
First
Last
Email Address
*
Phone Number
*
Video Chat ID (Skype, Google etc.)
How do you prefer I contact you?
*
Email
Phone
Skype or other video chat
Text
Tell me more about yourself.
By learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs.
Gender
*
Male
Female
Other
Date of Birth
*
Date Format: MM slash DD slash YYYY
What is your hight?
*
What is your weight?
*
What do you want?
*
In general, what are your goals? Check all that apply.
Lose weight / fat
Gain weight
Maintain weight
Add muscle
Improve fitness
Look better
Feel better
Have more energy and vitality
Get control of eating habits
Physique competition / modeling
Improve athletic performance
Get stronger
Please list all of your concerns about your health, eating habits, fitness, and / or body.
*
Out of all of the above concerns, which ones feel most important / urgent?
*
Why?
*
What do you expect?
What do you expect from me as your coach?
*
What are you prepared to do to work towards your goals?
*
What do you want to change?
Have you tried anything in the past to change your habits, your health, your eating, and / or your body?
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Yes
No
If so, what?
Which of those things worked well for you? (Even if you might not be doing it right now.)
Which of those things didn't work for you?
How, specically, would you like your habits, your health, your eating, and / or your body to be different?
*
Have you already made changes to your habits, your health, your eating, and / or your body recently?
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Yes
No
If so, what?
If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be?
Until now, what has blocked you or held you back from changing these things?
Right now, how would you rank your overall eating / nutrition habits?
*
Eating Habits
Horrible
2
3
4
5
6
7
8
9
Awesome!!!
Why?
Are you regularly active in sports and / or exercise?
If so, approximately how many hours per week?
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No Exercise
Fewer than 5 hours
5-9
10-14
15-19
20 or more
What types of sports and / or exercise do you typically do?
Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
*
Fewer than 5 hours
5-9
10-14
15-19
20 or more
What other types of movement and / or activities do you do?
What’s around you?
Tell me a bit about your environment.
Who lives with you? Check all that apply.
Spouse or partner(s)
Child(ren)
Other family (e.g. parent, sibling, etc.)
Roommate(s)
Pet(s)
Do you have children? If yes, how many and what are their ages?
Who does most of the grocery shopping in your household? Check all that apply.
Spouse or partner(s)
Child(ren)
Other family
Roommate(s)
Me
Who does most of the cooking in your household? Check all that apply.
Spouse or partner(s)
Child(ren)
Other family
Roommate(s)
Me
Who decides on most of the menus / meal types in your household? Check all that apply.
Spouse or partner(s)
Child(ren)
Other family
Roommate(s)
Me
Right now, how much do the people and things around you support health, fitness, and / or behavior change?
Support Change
Not At All
2
3
4
5
6
7
8
9
Completely
What’s your health like?
Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
*
Yes
No
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
*
Yes
No
Right now, are you taking any medications, either over-the-counter or prescription?
*
Yes
No
On a scale of 1-10, how would you rank your health right now?
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Overall Health
Worst
2
3
4
5
6
7
8
9
Best
Why?
How are you spending your time?
In an average week, how many hours do you spend...
In paid employment?
At school or doing school work?
Traveling or commuting?
Taking care of others? (e.g. children, person with a disability, older person)
Doing other unpaid work? (e.g. housework, errands)
Volunteering?
Adding up all these things, how many total hours per week do you spend doing all these activities?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
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Busy-ness
Panicked
2
3
4
5
6
7
8
9
Relaxed
How is your stress and recovery?
Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel). Then assess as best you can:
Given all the demands of your life, what is your typical stress level on an average day?
Stress Level
No Stress
2
3
4
5
6
7
8
9
Extreme Stress
On average, how many hours per night do you sleep?
*
4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
How do you normally cope with your stress?
*
How ready, willing, and able are you to change?
Right now, on a scale of 1-10
READY
*
Not At All
2
3
4
5
6
7
8
9
Completely
WILLING
*
Not At All
2
3
4
5
6
7
8
9
Completely
ABLE
*
Not At All
2
3
4
5
6
7
8
9
Completely
Disclaimer
*
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.
I have read the disclaimer
