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Full name

Date of Birth

Year

Month

Day

Gender

Phone

Height (Feet, Inches)

Current Weight (lbs)

As briefly as possible, what are your health and fitness goals (i.e. lose X amount of weight, improve energy and vitality, guidance for a specific event, sports performance):

What do you feel your current nutrition and health plan is lacking or holding you back from reaching this goal?

On a scale of 1-10 (10 being EXTREMELY), how ready are you to change your lifestyle?

Anything else I should know?

How did you hear about my coaching? (friend, social media etc.)

Disclaimer

Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation.

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Date

Year

Month

Day