Full Name:
Date of Birth:
Gender: MaleFemaleNon-Binary
Email Address:
Phone Number:
Preferred Contact Method: PhoneEmailText Message
What is your main weight loss goal? Lose X poundsImprove overall fitnessOther
If other, please specify:
What motivated you to join this program?
What challenges have you faced with weight loss in the past?
How would you describe your current activity level? SedentaryLightly ActiveModerately ActiveVery Active
Do you have any medical conditions or injuries we should be aware of? YesNo
If yes, please list them:
What kind of support do you feel you need most? (Check all that apply) Motivation and accountabilityMeal planning and recipesExercise routines and guidanceEmotional supportProgress tracking
How did you hear about our program? ReferralSocial MediaWebsiteAdvertisementOther
Is there anything else you’d like to share with us before we get started?
