×
Individual
Corporate
Content Corner
Free E-Books
Blog
Photography
Podcast
Testimonials
About/Contact
Client application
*
Indicates required field
Name
*
First
Last
Email
*
Height (inches)
*
Weight (lbs)
*
Age
*
What is your goal?
*
Please be specific. If your goal is to lose weight, how much do you want to lose?
Why do you want to achieve this goal?
*
Be as honest and transparent as possible.
What are your barriers?
*
What's holding you back? Time? Accountability? Knowledge? Support? Motivation?
Rate your current motivation on a scale of 1-10
*
10 being highly motivated and 1 lacking motivation
how many hours of sleep do you get per night
*
On average
General & Medical History
DOES YOUR OCCUPATION CAUSE YOU MENTAL STRESS?
*
Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
*
Rate your stress on a scale of 1-10
*
10 being high stress and 1 being low stress
Medical
HAVE YOU EVER HAD ANY INJURIES OR CHRONIC PAIN?
*
Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
*
HAVE YOU EVER HAD ANY SURGERIES?
*
Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
*
HAS A MEDICAL DOCTOR EVER DIAGNOSED YOU WITH A CHRONIC DISEASE, SUCH AS HEART DISEASE, HYPERTENSION, HIGH CHOLESTEROL, OR DIABETES?
*
Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
*
ARE YOU CURRENTLY TAKING ANY MEDICATION?
*
Yes
No
IF YES, PLEASE EXPLAIN. (IF NO, TYPE N/A)
*
DO you have a history of Eating Disorder?
*
Yes
No
If yes, please describe in detail your ED History.
*
Additional Information
IS THERE ANY ELSE YOU THINK I MAY NEED TO KNOW THAT MAY EFFECT YOUR ABILITY TO TRAIN. (THIS IS OF COURSE IN TOTAL CONFIDENCE).
*
Is there anything else you think I may need to know about your fitness goals?
*
Client Agreement
SESSION PACKAGES WILL BE MUTUALLY AGREED UPON. YOUR CONTACT DETAILS ARE SECURELY HELD AND WILL REMAIN CONFIDENTIAL.
*
I understand
Nutrition Coaching has a 3 month minimum requirement. After 3 months, clients can go month to month.
*
I understand
I HAVE AGREED TO UNDERTAKE IN A NUTRITION COACHING UNDER THE INSTRUCTION OF ERIC STARK FROM 12:12 FITNESS. COACHING MAY INCLUDE, BUT IS NOT LIMITED TO, BODY METRICS, CALORIE COUNTING, MEASURING/WEIGHING FOOD, ETC. ERIC STARK FROM 12:12 FITNESS AGREES TO INSTRUCT, ASSIST IN THE COACHING PROCESS. I REALIZE THAT A LARGE PORTION OF MY SUCCESS WILL BE BASED ON MY COMMITMENT TO FOLLOW INSTRUCTION, CHANGING MY LIFESTYLE, AND MY CONSISTENCY WITH MY NUTRITION HABITS. 12:12 FITNESS CANNOT GUARANTEE RESULTS, BUT MY WILLINGNESS TO WORK HARD WILL IMPROVE THE OPPORTUNITY OF SUCCESS. I HAVE READ THE ABOVE POLICY AND AGREE TO ITS TERMS AS IT APPLIES TO MY INDIVIDUAL NUTRITION COACHING PROGRAM.
*
I agree
BY CLICKING ‘I AGREE’ & SUBMITTING THIS COMPLETED FORM, YOU CONFIRM THAT YOU HAVE READ, UNDERSTOOD AND COMPLETED THE PAR QUESTIONNAIRE AND ANSWERED ALL QUESTIONS TRUTHFULLY, TO THE BEST OF YOUR KNOWLEDGE.
*
I agree
Submit
Individual
Corporate
Content Corner
Free E-Books
Blog
Photography
Podcast
Testimonials
About/Contact