Which coach did you sign up to work wIth?*Steven MitropoulosRachel TomapatMatt MustilloMatt NormanDate* Date Format: MM slash DD slash YYYY Full Name* First Last Email* Your Age*Please enter a number from 16 to 100.Phone*Are you currently dieting?*YESNOCurrent weight*Please enter a number from 75 to 600.Height*Current goal(s)*Gender*MaleFemaleAre you employed? If so, what is your occupation?*YESNOAre you consistently following a set nutrition program?*YESNOWhat is your current diet, nutrition? Provide further details about your eating habits? PLEASE BE AS SPECIFIC HERE AS POSSIBLE*Are you maintaining, gaining, or losing weight on your current nutrition/ diet?MaintainingGainingLosingIn the past 2 years how much time have you spent in a calorie deficit or attempting to be in calorie deficit via “yoyo dieting”?How many days would you prefer to workout per week? SELECT ONE (Think about sustainability and what you would be able to consistently commit to each week)3 Days4 Days5 DaysWhen do you prefer to workoutearly morninglate morningafternoonnightWhen do you prefer or able to do cardio?Fasted in the morning (empty stomach before first meal)Directly after workoutDoesn’t matterAre there any specific days of the week you need to have OFF from workouts?*How many meals do you eat currently?*How many meals do you prefer to eat a day?456What meal number will be your pre-workout meal?*Describe your daily schedule:*Do you have any concerns regarding your digestion ? (ie: bloating, cramping, diarrhea, constipation, reflux, burping, etc…)*Bowel movement frequency:Less than 1x per day1x per dayMore than 1x per dayHow much sleep do you get per night? SELECT ONE4 hours5 hours6 hours7 hours8 hours8+ hoursAny allergies/intolerances to food or medication? If so, please list.*Are you currently on any medications? If so, please list below (this includes if you have recently in the last month stopped any)*Female clients- Are you currently on birth control medication? If so, what kind?*Female clients- do you have a regular menstrual cycle)YesNoAny current injuries I should be aware of? Any previous injuries or surgeries?*Are there any foods you dislike, or won't eat?*Are there any foods you would love to see included in your daily nutrition that would help you be more consistent in following your plan?*Be realistic here --- examples: pasta, English muffins, cereal, bagel, wraps etc.Do you have recent blood work results? (Within the last 2 months). If not, are you able to get blood work done?*Do you currently use or have you in the last 3 months used PEDS? If so, please list…*IF NOT PLEASE PUT NO OR N/ADo you smoke tobacco products?YesNoDo you drink alcohol?Yes, occasionallyYes, oftenNoWhat do you feel is more important in achieving your goals? SELECT ONEMotivationConsistencyAre there any obstacles you're facing that may impede your success?****** By completing this questionnaire you acknowledge that you are required to give 14 days’ notice prior to cancelling services otherwise you will be required to pay per normal based on pricing agreement for the current month. ALL PLANS ARE REQUIRED TO A 3 MONTH COMMITMENT (payment for 3 months NOT due up front, only the first months payment is)Add your name again below, as your signature and acceptance of this agreement* First Last Please Upload FRONT/BACK and SIDE photos of yourself so we can get started. Drop files here or Accepted file types: jpg, gif, jpeg, png. Δ