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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)

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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)

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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)

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Behavioral Questions:
*
- 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)

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Training & Work-Out Routine:
*
- 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)

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Lifestyle & Health:
*
- 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)

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Before and After Photos:
Upload Image 1
Upload Image 2
Upload Image 3

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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.
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- I accept the fitmelle full terms and conditions
Your Name / Initials*

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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.

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