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Consultation Form (Gen)
1
Full Name
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First Name
Last Name
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2
E-mail
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3
Gender
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Male
Female
Other
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4
If qualified, do you have preferred start date?
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Month
Day
Year
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5
Age
years
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6
Weight
*
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lb
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7
Height
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Inches
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8
Contact
Country Code
Area Code
Phone Number
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9
Referred by? If YES please provide the name.
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10
What do you do for a living?
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11
Describe your familiarity with counting calories and macros. If you don't have any experience, are you willing to learn?
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12
Do you smoke? If YES how many per day and if you recently quit how long ago? and are you on nicotine patches?
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13
Check any that applies
I am looking to lose body fat and "get ripped"
I am looking to build lean muscle mass
I am overweight or obese, looking to lose weight and fat and overall improve my health status
I am interested in competing in bodybuilding, bikini, figure or lean out for photo shoot
I have weird "work" schedule and want a flexible training and nutrition program .
I am a busy mom and need a short & flexible training and nutrition and still achieve my body goal
I am busy entrepreneur I need a program to fit my busy life so i have more time to build my business while staying in shape.
Hmm? I don't know maybe I just want to look great naked.
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14
If known, what is the current amount of daily calories?
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15
Within the last 6 months have you lost weight ? 15lbs or more? and regained it all back?
YES
NO
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16
If yes, Did you gain everything or any weight back?
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17
What personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?
Lack of motivation
Time
Self Conscious
Lack of equipment
Lack of Results
Hitting A Plateau
Not knowing where/how to begin
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18
Do you currently exercise on a regular basis?
Yes
No
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19
If yes, how many days a week?
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20
Do you have access to fully equipped gym?
Yes
No
Limited Access or partially equipped
Home Gym or willing to invest (resistance bands, kettle bells or dumbbells)
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21
Average Daily Activity For The Day
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Minimal or no exercise for the day.
Low
Medium-Low
Medium
Medium-High
High
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22
What do you think is your biggest challenge in achieving your goals?
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23
What have you tried in the past that has not worked for you? And what has worked for you?
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24
What energizes you in the present? Think about a recent moment when you were happy. What was it about that moment that made it good for you?
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25
What motivates you?
Need a strong motivator to push you to exercise
You like to be informed about your program and how it is going to lead you to your goals
Like to try new things if they are effective
Willing to push past your comfort level to reach your goals
if I feel things are really hard I tend to back off
Need to be held accountable for what I am doing
Being sore the day after a workout tells me my workouts are working
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26
Please rate your motivational level to do what it takes to reach your goal.
1
2
3
4
5
6
7
8
9
10
I have no motivation.
I'll do anything it takes!
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27
Which newsletter you would be interested in receiving in the future?
fat loss tips
Supplements
Different Types of Training & Techniques
Diet & nutrition method
Stubborn Belly Fat
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28
What is best way to contact you?
Phone
Facebook or Social Media
Text Message
Email
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29
Are you ready to invest accomplishing your goals TODAY?
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