New Online Training Client Intake Form

Let's start with the basics.

What is your first and last name?

What's your best email?

When is your birthday?

What is your phone number?

What is your address?

What's your favorite podcast?

What's your favorite book?

Let's dive deeper.

What are your goals?

Lose weight / body fat

Gain weight

Maintain weight

Add muscle

Improve overall fitness

Look better

Feel better

Have more energy

Get stronger

List your top 3 concerns you have about your health, eating habits, fitness, and/or body.

Why did you choose those 3?

What made you reach out and apply for the 90 Day Midlife Reset Program?

What aren't your willing to do to reach your goals?

How long have you been wanting to get back into great shape?

What have you tried in the past when it comes to losing fat and building muscle?

If it didn't work, why do you think?

If you could solve the problem of getting back into shape, how would it change things for you?

The 90 Day Midlife Reset Program requires 4 training session per week. Is this realistic for you?

The 90 Day Midlife Reset Program teaches you to eat 3 times per day with a post workout shake and no snacking. Are you willing to try this approach?

The 90 Day Midlife Reset Program requires you get a DEXA scan (bodyfat testing). Are you willing to do that? (it's really easy).

Are you willing to invest $199 per month to regain your health, strength, and vitality?

What's your health like?

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

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

What, if any, specific health concerns, such as illnesses, pain, and/or injuries do you have?

What, if any, medications, either over-the-counter or prescriptive, are you taking?

On a scale of 1-10, how would you rank your health right now?

0 being "it totally sucks" and 10 being "I should be my own species I'm so healthy"

Disclaimer

It is your responsibility to work directly with your health care provider before, during, and after seeking nutrition, fitness, and behavior change help. Any information provided by (YOUR BUSINESS NAME) is not to be followed without prior approval from your doctor. If you choose to move forward with the information provided without your doctor's approval, you agree to accept full responsibility for your decision.

By clicking the yes button below, you're agreeing to the disclaimer and that all of the information you've provided above is accurate and up to date to the best of your knowledge.

Untitled multiple choice field

Yes

Book your call

Look at the calendar below and book a call at a time that works best for you. Looking forward to chatting with you!