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Let’s get to know one another!
What is your “Why?”
Please answer the questions below in as much detail as possible. This will allow me to gain a better understanding of your top priorities, goals and concerns. Upon submitting, I will be in touch regarding next steps. Thank you, and congratulations on taking this important step towards being your most confident, beautiful, bada** you!
Name
*
First Name
Last Name
Phone Number
*
Email Address
*
Date of Birth
*
MM
DD
YYYY
How did you hear about me?
Facebook
Instagram
Word of Mouth
Google
Twitter...that's funny, I don't even have a Twitter account
Have you completed any of my past programs? If so, which one?
On a scale of 1 to 10, how would you rate your present fitness level (10 being the highest level of fitness possible)
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How often do you participate in physical activity?
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I have not participated in physical activity for the last 6 month
1-2 times per week
3-4 times per week
5-7 times per week
Other
If active, please list the activities you currently participate in (walking, jogging, strength training, swimming, hiking, yoga, biking, etc.) and the frequency per week of each activity.
What type of workout program are you looking for? Check all that apply.
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Strength Program (with limited equipment)
Strength Program (bodyweight only)
Strength Program (gym based, full equipment)
Cardio (HIIT, Tabata, etc.)
5k, 10k or half marathon training
What type of equipment do you have access to? Check all that apply.
*
Full Gym
Dumbbells
Resistance bands with handles
Loop Resistance Bands
Mini Loop Bands
Stability Exercise Ball
Weighted Medicine Balls
Slam Balls
Kettlebells
Pull up Bar
Jump Rope
Agility Ladder
Foam Roller
Other
What obstacles and challenges have you faced in the past that kept you from achieving your goals? Check all that apply.
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Lack of Motivation
Lack of Time
Boredom
Health Issues/Injury
Money
What are you hoping to gain out of working with me? Think big picture goals here!
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How can I help to motivate you?
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Have you had a personal trainer or health coach in the past? If so, what did you like and/or dislike about your training program and/or trainer?
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On average, how many hours of sleep do you get per night?
*
Are you on any medications I should be aware of? If so, please list them.
*
How would you rate your quality of sleep?
*
Low
Medium
High
How would you rate your stress level?
*
Low
Medium
High
What are some ways you cope with stress? (Meditation, yoga, breathing, eating, going for a walk, gardening, playing piano, exercising, etc.) Please list.
*
Do you have any health conditions I should be aware of? If so, please list them in detail.
*
Do you have any injuries or physical limitations? If so, please list them in detail.
*
Are you happy with your body? Please explain your answer
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What positive things have you already implemented to make peace with your mind and body?
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What do you want your relationship with eating and food to look like 6 months to 1 year from now?
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On a scale from 1 to 10, how open are you to trying new things (1 being "not ready at all," and 10 being "let's do this!"
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Favorite quote to live by?
HOORAY! Let's do this!
Thank you for taking the time to fill out this information. Remember, all of your answers will remain confidential. I will be in touch shortly with next steps and further details!
By submitting this form, I acknowledge that the I take full responsibility for my life and well being, as well as the lives and well being of the my family and all decisions made during and after this Program. I expressly assume the risks of the Health and Fitness Program, including the risks of making nutrition, lifestyle and fitness changes. I release the Coach and Personal Trainer from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which I ever had, now have or will have in the future against the Coach, arising from my past or future participation in, or otherwise with respect to, the Health and Fitness Program, unless arising from the gross negligence of the Coach. I, the Coach, will keep the Client's information private, and will not share the Client’s information to any third party. -Sally Willoughby
Signature
*
Thank you for your submission. I will be in touch shortly!
Thank you - you rock!
