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Name*

First Last

Phone Number*

Email Address*

What are your goals?*

(related to fitness, habits, nutrition, etc.)

What have you tried in the past to accomplish your goals?*

(e.g. What kinds of workouts have you tried? Have you tried any specific dieting or nutrition plans?)

What current challenges are preventing you from accomplishing your goals?*

(e.g. lack of time, not knowing what to do, stress, etc.)

What would be the most beneficial aspect of an online coaching program?*

(e.g. Accountability, Consistency, Nutritional Knowledge, etc.)

Lifestyle*

(sedentary, commute, active, etc.)

Medical History*

(conditions, injuries, pain, etc.)

Commitment Level*

(on a scale of 1 to 10, with 10 being the most committed)

Days Committed to Training*

Long-term, how many days per week are you willing to commit to training?

1-2

2-3

3-5

5-7

Height*

Weight*

Age*

Do you have any other questions or concerns about training with me?

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