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Holistic Method Consultation Form
Please fill this form with as much detail as possible
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Birthday
*
MM
DD
YYYY
Height
*
Weight
*
Goals / Expectations
*
Please be clear. Include mental, physical, spiritual, relationship, career, lifestyle goals.
Current Workout Routine
Do you tend to have a regular form of exercise or looking to begin a routine? Do you play sports/outdoors? Regular walks/cardio?
Available Equipment
Check the boxes for the available weights in your gym/home
Dumbbells
Kettlebells
Bands
Mini Bands
Cables
Barbell
Sled
Battle Rope
Swiss Ball
Bosu
Slamb Ball
Landmine
TRX
Sliders
How many days a week do you want to workout in the gym?
1
2
3
4
Food Preferences / Allergies
*
What foods do you prefer to eat? Do you know of any food allergies? Do you enjoy cooking?
Recent Meals
Recall meals over the last week. (3-6 is great)
Daily Activities / Lifestyle
What are your hobbies? Do you tend to stay active or sedentary? Do you tend to spend more time indoors or outdoors?
Supplements / Prescriptions
What supplements do you take? What prescriptions do you take?
Current / Past Injuries
Any current injuries or past injuries. Constant or occasional pain?
Medical History / Family History
Job/Career. Your Relationship To it (like/dislike)
Stress Management Techniques / Self Development
Sleep Quality
*
1- Poor
2
3
4
5- Great
Energy Stability Throughout Day
*
1- Up and down all day
2
3- Somewhat stable, midday crash
4
5- Stable energy all day
Confidence
*
1- Low
2
3
4
5- Very confident
My thoughts-words-actions are impeccable. I think-speak-take action in alignment with my purpose
*
1- No awareness around this or poor discipline
2
3
4
5- In alignment and true to myself
I am growth mindset and ready to take action on my goals NOW!
*
1- Unsure and hesitant
2
3- Ready and applying some growth but ready to step up
4
5- All in, lets go!
Additional Information
Thank you!