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Personal Information

Full Name

Date of Birth

Height

Weight

Activity & Exercise

Level of Daily Activity

Low Sedentary — mostly sitting throughout the day Medium Mix of sitting and standing during the day High On your feet most or all of the day

Days of Exercise Per Week

Goals & Health

Your Goals

Health Concerns

Lifestyle

Hours of Sleep Per Night

Current Stress Level

Preferred Coaching Style

Tough Love Direct, no-nonsense, and motivational Gentle Encouragement Supportive, patient, and compassionate Just Give Me a Plan Tell me what to do and I'll handle it

What Do You Struggle With Most?

SELECT ALL THAT APPLY

If "Other," please describe

How Did You Hear About Us?

If referred by someone, who should we thank?

Acknowledgment

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that nutritional coaching through Fueled4Life is not a substitute for medical advice, diagnosis, or treatment.

Signature

Date

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New Client
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