Weight Loss Consultation Form

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Height

ft

Weight

lb

Target Weight

lb

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

How would you like me to contact you?

At what times during the day would you prefer a follow-up?

What do you do for a living?

Do you follow a regular working schedule, do you work days, afternoon or nights?

What is your Activity Level per Week?

What are your Priorities?

Please list the physical activities that you participate in outside of the gym and outside of work.:

If you have any diagnosed health problems list the condition(s).

Are you experiencing any stress or motivation problems?

Your current diet could be best characterized as:

What is your goal with this program?

What do you expect from me as your coach?

How soon are you ready to Start?