Name * First Name Last Name Email * Phone (###) ### #### Which Plan are you interested in? Monthly Six Month One Year Date When do you want to start? MM DD YYYY Give me a description of what you are trying to accomplish... Do you have a commercial gym membership? What is the name? What areas of health & fitness do you feel you need to focus on? Training (resistance, hypertrophy, cardio) Nutrition (food choices and meal timing) Accountability and structure (following a plan/check-ins) Making lifestyle changes for long term success How many meals a day do you eat? 1 2 3 4 5 6 Do you drink coffee? If so, how much and how often? Give me a typical day of eating, meal by meal (be honest). Try to give me an example, even if you've been all over the place. Choose desired number of meals per day (4-6) 4 5 6 Are you familiar with macronutrients (macros: protein, carbs, fats)? Allergies to food or anything else? How would you describe your health? Excellent Good Fair Poor Are you currently taking any prescription meds? What over-the-counter meds, vitamins, supplements (be specific) do you take? Prior medical history (any limitations), including surgeries. Any current injuries? Occupation and regular work schedule/routine How many days a week do you currently train? and what time of day? What is your current training split? What set /rep ranges are you using, and how much time between sets? Any exercises / movements you cannot do due to previous injuries? Current amount of cardio per day? Type of cardio (walk, elliptical, jog, treadmill etc.) and when? Are you serious about your goals? This will require follow-through and grit. I need your word that you are willing to work hard and follow the plan to a T--if you do the results will speak for themselves Age / Height / Weight Thank you! I will be in touch with you very soon…-Jeff Reiman Application for Coaching Always consult your physician prior to participating in any exercise and diet program
