| Full Name: |
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| Best Contact Phone Number: |
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| Best Contact Email Address: |
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| What are the top 2-3 reasons you want to improve your personal health: |
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| How committed are you to improving your health on a scale of 1-10: |
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| Rate your current exercise habits on a scale of 1-10: |
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| Rate your current nutritional habits on a scale of 1-10: |
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| Describe what you eat on a typical day: |
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| What road blocks or struggles do you face when it comes to leading a healthy life: |
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| What are your health and fitness goals: |
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| What do you feel needs to change in order to achieve your goals: |
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| Explain how your life would be different if you met all your fitness goals: |
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