EmailMe Form

Name

First Last

Email

Phone

### - ### - ####

Height

Weight

Birthday

Age

Any injuries, major surgeries, chronic diseases/medical diagnosis. Please provide as much detail as possible

Has your doctor ever diagnosed you with a heart condition? If so, what kind?

Do you ever lose balance, have dizziness, chest pain or something else while engaging in physical activity? Please Explain

Do you have high blood pressure? If so, please detail medications (if any)

Favorite style/type of exercise(s)

Least favorite style or type of exercise(s)

Current Occupation

Do you wear heels often?

Do you sit during most of your day?

How often do you workout today (days/week) and for how long (duration per session)?

Rate your GOALS in order from 1-8 in order (1 being your MAIN goal)

Improved Health
Increased Strength

Improved Endurance
Sport Specific

Increased Muscle Mass
Increased Power

Fat Loss
Weight Gain

Do you have a specific timeframe for achieving your goals? If so, please explain:

Please provide measurements in inches on the following:

Neck
Chest

Left Bicep
Right Bicep

Waist
Hips

Left Thigh
Right Thigh

Left Calf
Right Calf

Please provide at least 3 days and times that you are available to have an assessment call.

Please provide any additional detail that will be helpful to know about your nutrition such as: 1.) any supplements you take 2.) how often you go out to eat or order take out 3.) if you meal prep, how are you doing it today, and 4.) any food allergies or restrictions:

Are you ready to get started right away?

Yes

No

Within 2 weeks