What is your full name?

The name you use on facebook

What is your age?

What is the best number to reach you at? *

What is your email? *

Where are you located?

State/Province & Country

What is your height? (feet)*

What is your current weight?

What is your number one struggle right now and how has it been holding you back from achieving your goals?

Which program are you most interested in?

Custom Nutrition

Custom Nutrition & Training Program

Custom Training Program

Do you exercise currently?

Yes

Have you done any specific workout / nutrition programs, specific diets etc in the past or currently?

1=unhealthiest you've ever been - 10=healthiest you've ever been

Do you have any current or past Injuries?

Please Upload Front, Side, and Back progress pics.
No one will see these but me
Example photos and file upload are shown below.

Front Progress Pic

Side Progress Pic

Back Progress Pic

Where do you train?

Gym

Home: No Equipment

Home: Some Equipment

Home/Gym

How many steps do you average per day?

*Average in America is 3,000-4,000 Per Day*

Provide a typical full day of eating, including beverages & supplements. Explain what you eat, including portion sizes for each food item & when you eat it.

*This needs to be a real day of eating. Include junk food if you regularly consume it. The more honest you are, the better I can coach you & help you.

What do you usually eat when you go out for food?

What are your favorite foods?

Do you have any food allergies and/or food intolerances?

Yes

Do you use smokes regularly?

Yes

*Tobacco Cigarrets*

Do you drink alcohol regularly?

Yes

Do you take any vitamins or supplements?

What is your job? And how active are you in it?

How are you approaching this application?

I have less than $250 to spend, I just want something basic.

My budget is tight, but if the program guarantees results I'm committed!

I'll do whatever I have to do to accomplish my fitness goals!

What is your WHY & PURPOSE for wanting to make these changes to your health & lifestyle?

Be descriptive and give fine detail. This answer factors in heavily in qualifying for the Altered Fitness Program.

On a scale of 1 - 10 how committed are you to achieving your goals? 10 being 100% committed!

7 or below

10!

Is there anything stopping you from getting started today?

What are you looking to gain from this coaching experience?

Describe with fine detail*

Why do you want to work with me? Our coaching program is not a cheap "cookie-cutter" or "one size fits all" program. It's hands-on 1-on-1 coaching tailored to your specific life, goals, and needs. Are you willing/ready to invest in yourself and hire a coach?

What are your short term (1 to 3 months) and long term (6 to 12 months) goals?

If you were referred by a friend or current member please list there name here!

When would you like to start?

Please allow 3-5 business days for the program to be built, and designed.

Do you have any other questions, or want to tell me anything else about yourself?

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Please Upload Front, Side, and Back progress pics. *No one will see these but me* Example photos and file upload are shown below.

Please Upload Front, Side, and Back progress pics.
No one will see these but me
Example photos and file upload are shown below.