I know sharing some of the info on this form can make you feel a little vulnerable, but I can promise you, that you won’t regret getting started with me! My goal is helping you in making lifestyle changes and
achieve sustainable results,
so it’s important that I get to know your needs, goals and struggles, which is what this form will help me do! So please take it seriously 🙂
Fill out the form below and I’ll get back to you in the next 24-72 hours, with your personalized health and fitness plan recommendations.
I will also let you know if you have been selected for a spot in my 1-on-1 or group VIP Coaching Program. I truly wish I could work with everyone, but I have to make sure I limit the amount of new clients I take on at one time, so my clients get the best support and results! If not you will be placed on the waiting list for open registration, I hope you understand!
Custom Health & Fitness Questionnaire Form
Step 1 of 2 - 1
What is your name?
What is your name as it appears on Facebook?
What is your Email address?
This is how I will send you your free custom plan so double check the email!
What is your phone number?
Energy is everything. Tell me how you feel:
Honestly, I feel like crap. My energy is non-existent and I struggle to stay positive.
My energy is up and down and so is my mood.
My energy stays pretty high, and I consider myself well balanced and generally positive.
I have AMAZING energy ALL THE TIME. I love life and today is always THE BEST DAY EVER!!!
Do you like to get physical? Tell me about your weekly physical activity!
Very little movement each day other than normal daily activities (no physically demanding job either).
I have a physically demanding job, but do not add extra working out on top of that.
Work in Progress. I make a conscious effort to workout 1-2 times a week)
I have a physically demanding job, but add on workouts when I can. (Nurse working 12 hour shifts etc)
Fitness is on my Mind. I try to workout 3-5 times a week.
Working out is a priority to me. I do a legitimate workout once a day at least 5-6 days a week
LOVE my workouts. Some call me obsessed, I call it dedication! It's my form of therapy!
What kind of workouts do you typically enjoy doing?
Choose as many as you'd like
At the gym
For the love of food, tell me about your current eating habits:
I eat clean - If it’s processed, it’s not getting near this body.
I eat generally pretty well but fall off the wagon every now and then and have to get back on.
I have an awareness of healthy eating and make a conscious effort…but late night ice cream or potato chips are kind of my jam.
Fast food, sodas, and packaged snacks are no strangers to me.
Tell me what a typical day of eating looks like for you right now.
Do you use any supplements?
If yes what?
Do you drink/take anything for energy? (coffee, energy drinks etc..)
Tell me how well you slay the stress in your life:
I rarely feel "stressed out"
There is stress in my life, but I tend to cope fairly well and rarely freak out.
I have multiple areas of stress in my life, and I have a difficult time keeping it all together.
Stress is an all the time thing for me, and I feel on the verge of a breakdown frequently.
Check all that apply
Choose as many as you'd like
I'm constantly reaching for carby/starchy foods and can't seem to stop craving them (Even the healthy ones)
I'm constantly hungry and can't seem to ever feel satisfied
I'm eating "healthy" and still not seeing/feeling changes
I think about food at least once every 30 minutes
I reach for carbs or more cofee as a pick-me-up
I find myself eating more, even though I'm not hungry
I've avoided social situations, because of negative feelings and even physical symptoms I have had from overeating
I am a super picky eater so it is too hard to eat healthy foods.
I eat differently in private than I do in front of other people
I feel like I need to snack all day long
I obsessively calculate the calories I've burned against the calories I've eaten
I eat out of boredom or emotion
I'm waiting for my life to begin "when I lose the weight"
I feel like I've always been on some sort of "diet" without long-lasting success
I have elevated urges to consume certain foods when I try to cut down or stop eating them
I lack support at home or with my social circle
I struggle with chronic yo-yoing
I feel addicted to sugar/carbs
I constantly feel tired or lethargic
I often have brain fog or feelings of loss of attention
I feel STUCK!
I get winded and out of breath doing regular household chores.
I don't have time to workout or prepare healthy meals.
I get bored easily with the same workout.
You are a
What is your age range?
55 or older
Check any of the following that apply to you:
Choose as many as you'd like
Diabetes (type 1)
Diabetes (type 2)
High Blood Pressure
Not eating enough greens
Binge Eating/Emotional Eating
Do you have any other medical conditions or injuries?
What do you struggle with the most as far as your nutrition and fitness?
Knowing what to eat? How much to eat? Time? Injuries? Limitations?
What are your health and fitness goals? Having a vision and measurable goals is SO important!
Please take your time answering this question
What's your goal body? Keep in mind YOUR body type and what's realistic. Upload a picture from pinterest, google, or maybe it's a picture of you previously!
If you're 5'2" and have an hourglass figure, you don't want to be striving for a picture online that is of someone naturally thin, no curves, unrealistic thigh gap and 6'1"
Drop files here or
Accepted file types: jpg, gif, png, pdf.
WHAT or WHO really motivates you to live a healthy and fit lifestyle?
Who do you admire? Who do you follow? Who do you look to for inspiration? WHAT inspires you? It could be a friend, public figure, your kids... anything!
What's your reason for wanting to make changes now?
(Think DEEP here --- your kids, health, family...)
Any other information you would like for me to know about you? I'll be in touch within 24 hours of receiving your application! Be sure to check the email you provided. I can't wait to get to know you more!
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