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CONSULTATION FORM
General Information:
Name/Instagram Handle
*
Phone Number
*
E-mail
*
Age
Weight
*
Height
*
Body Type Percentages
Endomorph %
*
Mesomorph %
*
Ectomorph %
*
What are you trying to accomplish?
*
Why do you want me to assist you?
*
Budget
Budget
Sorry, but this budget is not enough to start our program.
Diet Only
(This is a one time fee)
Diet & Training
(This is a one time fee)
Fully Custom Diet & Training
(This is a one time fee)
Daily Accountablity
(This is a one time fee)
Learning About You:
Which of these statements are true. (check all that apply)
*
I am happy with my reflection when I look in the mirror..
I'm preparing for my Summer body.
I want to lower my body fat percentage while keeping my lean muscle mass.
I want to play outside with my kids more.
I want to be an IG model.
I just want to learn how to prepare healthier meals.
I want to learn how to eat what I want and still achieve my goals
I have lost the same 10 pounds five times this year.
I don’t need to lose weight; I just need to tone up.
I am self-consciousness about working out around others.
I am interested in gaining weight.
I just want to build a bigger butt.
(check all that apply)
Eating History:
Please select all that apply.
*
Vegetables are disgusting.
I have dietary restrictions.
I eat three meals a day.
I eat 4-5 times a day.
I already track macros.
I’m too busy to eat.
I don’t eat pork.
I’m vegan.
I’m pescatarian.
I’m vegetarian.
I don’t eat beef.
I love all meat.
I don’t like to eat.
Pizza is my weakness.
I eat when I get upset.
I have unhealthy cravings during my cycle.
I’m not eating enough to gain weight.
I am willing to change my eating habits to reach my goals.
I drink coffee/tea every day.
I love sodas.
I drink a gallon of water every day.
I drink less than a gallon of water each day.
(click all that apply)
Behavioral Questions:
(click all that apply)
*
I’m impulsive.
I think on things for weeks.
I like trying to new things.
I often start task and do not complete them
I like to cook.
I hate to cook.
I’m self-sufficient.
I weigh myself daily.
I weigh myself once per week.
I don’t own a scale.
My fitness personality is Goal-Weight Seeker
I am assertive.
I make short and long-term goals for myself.
I don’t believe in goals; only achievements.
I believe weight loss can be achieved without hard work.
I like 21-day challenges.
(click all that apply)
Training & Work-Out Routine:
(click all that apply)
*
I work out 1-2 times a week.
I work out 3-4 times a week.
I work out 5+ days a week.
I love to lift weights.
I hate lifting weights.
Cardio only, Baby!
I only like training at home.
I love training in the gym.
I have a professional trainer.
I love home work-out DVDs.
I love body weight training.
I’m afraid I’m going to look like a man.
I’m afraid of losing my breast/butt.
I have bad knees.
I like training in group environments.
I have a spotter.
While working-out, I have to look good.
I feel intimidated in the gym.
(click all that apply)
Lifestyle & Health:
(click all that apply)
*
I work third shift.
I’m on my feet all day.
I have a desk job.
I’m a mom.
I’m in school.
I have a full-time job.
I work more than one job.
I’m a stay at home mom.
I get less than 6 hours of sleep each night.
I get 6-8 hours of sleep every night.
I have insomnia.
I have sleep apnea.
I drink alcohol often.
I’m under a lot of stress.
I’m on medication.
I’m on Birth Control.
I’m Pregnant/ Trying to conceive.
(click all that apply)
Before and After Photos:
Upload Image 1
Max. file size: 32 MB.
Upload Image 2
Max. file size: 32 MB.
Upload Image 3
Max. file size: 32 MB.
Terms & Conditions:
You must be 18 years or older to submit a consultation
Please be advised that I am not a certified Dietitian/Nutritionist or Personal Trainer. I am simply a person who wanted to see changes in my diet and exercise routine, which resulted offering diet & training services. By agreeing to these terms & conditions you are aware of this and would like to submit your consultation.
Untitled
I accept the fitmelle full terms and conditions
Your Name / Initials
*
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Start Here
Online Coaching
Kickstart
About Me
Blog
Contact
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I’m a fitness lifestyle coach and blogger. My passion is sharing my knowledge and thoughts about dieting and training while helping others achieve their long-term goals.