First Name
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Last Name
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Email
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Phone
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Date of birth
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Height
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Current Weight
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Weight Goal
How did you hear about us? / What brought you here?
What are your goals with this program?
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Lose Weight/Fat
Gain Muscle
Lose Some Fat While Building Muscle
Improve Relationship With Food / Control Eating Habits
Have More Energy
Feel Better
Look Better / More Confidence
Healthy Aging
Improve Overall Health
Improve Athletic Performance
Get Off or Decrease Medication
Physique / Modeling
Do you have any specific goals?
Out of everything above, what are the 3 most important things to you?
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Are there any habits you currently have that you would like to change?
What has stopped you from making those changes?
what have you tried previously to change your health, eating habits, or body?
Which, if any, of these have worked well for you and why?
Which of these haven't worked well in the past and why?
What is your current activity level?
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1: I'm completely sedentary
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10: I'm pretty much always moving or doing something
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When you are active, what does that look like?
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Who lives with you?
Spouse/Partner
Roommate(s)
Child(ren)
Pet(s)
Other Family
If you have children, what are their ages?
Right now, are you taking any medications, either over-the-counter or prescription?
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Have you been diagnosed, currently or in the past, with any significant medical condition(s) and/or injuries?
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Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?
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Who does most the grocery shopping in your household?
Who does most the cooking in your household?
How many meals do you prefer to eat each day?
Do you have any dietary preferences?
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How would you rank your health right now?
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1: What even is a vegetable?
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10: I am the epitome of health!
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On average how many hours per night do you sleep?
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1-4
5-6
7-8
8+
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Given all the demands of your life, what is your typical stress level on an average day?
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1: My life is rainbows and butterflies
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10: My life is panicked and insane
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Why is that?
How do you normally cope with your stress?
Right now, how much do the people around you and your environment support your health, fitness, and behavior changes?
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1: I'm pretty much on my own here
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10: I am fully supported
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How READY are you to change your behaviors / habits?
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1: nah, I like where I'm at
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10: I'm ready to make change now!
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How WILLING are you to change your behaviors / habits?
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1: Nah, I like where I'm at
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10: I'm willing to make change now!
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How ABLE are you to change your behaviors / habits?
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1: I don't see a way I'd be able to do this
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10: I'm able to make change now!
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What are you prepared to do to work towards your goals?
What do you expect from your coach?
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Is there anything else no discussed here that you want us to know?
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Who is the one person you would want to do this with you?
Who is someone you know that would also benefit from working with us?
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