Your FREE Consultation

Congratulations on Deciding that YOU ARE READY to make a change! Please fill out this form so I may have a better understanding of your history prior to our live consultation.

First Name*
Last Name*
Your Preferred Email Address*
Phone Number*
What is your : Age, Height, & Weight?
What is your goal weight?
What results do you desire? Weight and/or Health and Why?
What has worked for you in the past? Why and what did you like or dislike about these techniques?
Have you ever attempted or do you own any other Beachbody Home Fitness program such as P90X, Insanity or Turbo Fire?
Order the following from (1) Most Challenging to (5) Least Challenging?
Time Motivation Finances Support Knowledge
What family history concerns you?
High Blood Pressure
High Cholesterol
Heart Disease
Do you skip meals often?
Yes No
Do you have a history of an eating disorder?
Yes No
What are you BIGGEST weaknesses?
Do you lack energy and need caffeine mid-day?
Yes No
Do you take medication? Do you have any physical injuries? Explain.
Why is this a priority to you NOW? What made you decide to reach out?
How much water do you drink daily?
How many hours of sleep do you get?
Less than 6 hours
6-8 hours
More than 8 hours
Explain what a typical day looks like for you.
Which exercise are you most comfortable with?
I am HAPPY with my :
Spouse/Partner's Relationship
Child/ren's Relationship
Circle of Friends
Immediate Family Relationship
What ELSE would you like me to know?
Do you have family or friends that you would love to see make healthy changes with you?
Yes No
Have you ever used the services of a health and nutrition coach?
Yes No