New Client Application V2

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New Client Application V2

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39Questions

1
Age* This field is required.
20-30
30-40
40-45
46-50
50-55
56-60
60+
2
Sex* This field is required.
Male
Female
3
Height* This field is required.
Under 5'0
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
Above 6'5"
4
Weight (Pounds)* This field is required.
Under 100
100-110
111-120
121-130
131-140
141-150
151-160
161-170
171-180
181-190
191-200
201-210
211-220
221-230
231-240
241-250
251-260
261-270
271-280
281-290
291-300
301-325
326-350
350-400
400+
5
How Much Weight Do You Want To Lose (Pounds)?* This field is required.
10-20
21-50
51-75
76-100
101-150
151+
6
Do You Have Any Injuries?* This field is required.
Neck
Low back
Shoulder
Knee
Elbow
Ankle
Hip
Wrist
Mid back
Other
None
7
Any Previous Surgeries?* This field is required.
Neck
Low back
Shoulder
Elbow
Knee
Hip
Ankle
Foot
Adbominal
Heart
Brain
Wrist
Other
None
8
Do You Have Any Medical Conditions* This field is required.
High blood pressure
Type 1 diabetes
Type 2 diabetes
Cancer
Autoimmune disease
Asthma
Other
None
9
Are You On Any Medication That Would Affect Exercise/Weight Loss?* This field is required.
High blood pressure
Diabetes/blood sugar
Cholesterol
Antidepressants
Other
C'mon Blaine I'll Tell You Later
None
10
Do You Have Clearance From Your Doctor To Start An Exercise And Diet Program?* This field is required.
Yes
No
No, but I'll get it asap!
11
Do You Want To Train Online Or In Person (In Winnipeg)?* This field is required.
In person
Online
12
Occupation* This field is required.
Professional
Business owner
Retired
Other
None
13
What Are Your Goals?* This field is required.
Weight loss
Better health markers
Feel better
More energy
Better sleep
Stress management
More confidence
Other
14
What's Stopping You From Reaching Your Goals On Your Own?* This field is required.
Don't know what to do
No time
No energy
Always hungry/cravings
No motivation
No willpower
Need accountability
Need support
I'm outta control! Help!
Other
15
How Did You Hear About Me?* This field is required.
Facebook
Google
Instagram
Radio
Billboard
Client Referral
Mail
Business/Professional Referral
Other
16
What Else Have You Tried To Lose Weight?* This field is required.
Personal trainer
Weight Watchers
Zumba
Orange Theory
Spin classes
Yoga
Weight loss supplements
Online trainer
Fit Body
Keto
Fasting
Vegetarian
Cardio
Praying
Group classes
Other
None
17
What Would You Say Your Weight Training Experience Is?* This field is required.
Beginner
Intermediate
Advanced
18
What Would Be The Most Important Criteria For Success If We Work Together?* This field is required.
Weight loss
More energy
Better health markers(blood pressure, blood sugars, etc.)
Better sleep
Improved self confidence
Stress management
Be able to function better for activities for daily living
Other
19
On A Scale Of 1-10. 1 Being I'm Satisfied Where I Am And 10 Being I'll Do Anything To Reach My Goal What Number Are You?* This field is required.
1
2
3
4
5
6
7
8
9
10
20
What Would You Expect From Us As Your Coaches If We Were To Work Together?* This field is required.
Accountability
Support
Proper Guidance
Availability to ask questions
Motivation
Other
21
I Understand That Results Are Not Guaranteed And What I Put In Will Largely Dictate My Results.* This field is required.
Yes, I understand
No, I don't understand
22
I Understand That Any Type Of Exercise Program Does Carry An Element Of Risk However Small It May Be And That I Will Not Hold Anyone Responsible Should Any Instance Occur.* This field is required.
Yes, I understand
No, I don't understand
23
If Accepted How Soon Are You Looking To Get Started?* This field is required.
Yesterday
In the next week
In the next month
In the next 3 months
In the next 6 months
I have no idea I'm just checking things out
24
If We Work Together And You Have Not Only Reached Your Goals, But We Have OVERDELIVERED On Everything We Have Promised Are You Able To Refer 2 People Of Equal Stature As Yourself That May Need Our Services?* This field is required.
Yes
No
25
If We Are A Good Fit And I Feel I Can Help You Are You Willing To Put In A Solid Effort, Follow The Program, And Train Together For At Least 12 Weeks?* This field is required.
Yes
No
26
If You Are Happy With The Results And Our Services How Long Do You Plan On Staying With Us For?* This field is required.
3 Months
6 Months
1 Year +
Forever
Until I reach my goals
27
I Understand This Is A 4 Week At A Time Membership That I Will Be Charged Whether I Make It To All Or None Of My Sessions. I Am Paying To Hold My Spot, Ongoing Support, Education, And Gym Fee. These Charges Are Recurring Until I Cancel, Which I Can Do At Anytime.(For Training In The Gym)* This field is required.
Yes, I understand
No, I don't understand
28
What Type Of 4 Week Membership Are You Interested In?* This field is required.
Train 2x/Week $497
Train 3x/Week $697
Online $497
29
Are You Willing To Use A Credit Card For The Membership?* This field is required.
Yes
No
30
Training Times Flexibility. Are You Flexible With When/What Times You Train?* This field is required.
Yes
No
Somewhat
31
What Time Of Day Do You Want To Workout?* This field is required.
6am-7am
7am-8am
8am-9am
9am-10am
10am-11am
11am-12pm
12pm-1pm
1pm-2pm
2pm-3pm
3pm-4pm
4pm-5pm
5pm-6pm
6pm-7pm
7pm-8pm
8pm-9pm
AM
PM
Doesn't Matter
32
Do You Want To Train On Saturdays 8am-3pm?* This field is required.
Yes
No
33
I Understand That If I Book A Time That I Only Have An Hour And That If I Show Up Late My Workout Will Be Cut Short.* This field is required.
Yes, I understand
No, I don't understand
34
I Understand That If I Cancel An Appointment Last Second I Can Try To Rebook At Another Time That Week If There Is Anything Open.* This field is required.
Yes, I understand
No, I don't understand
35
Why Do You Think You Would Be A Good Addition To Our Program?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
36
Out Of All The Options Out There What Is The Reason You Decided To Contact Me/Possibly Want To Work With Me?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
37
Name* This field is required.
First Name
Last Name
38
Email* This field is required.
example@example.com
39
Phone Number. (This is your last question. Once you hit "submit" you will be redirected to a scheduling page to book a day and time for a phone call. PLEASE DO THIS!)* This field is required.
Area Code
Phone Number
Should be Empty:

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