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We’d love to hear from you! Fill out the form below to give us a better idea of your goals and lifestyle. If you’d just like to send us an email instead, click the button below!

Name *

Email Address *

How did you hear about us?

FriendSearchSocial MediaAdOther (specify)

Other:

Have you used a coach before?

Yes (please specify below)no

previous coaching experience:

Age

Gender

Height

Current Weight

Goals

Please select all goals that are important to you:

Weight LossWeight GainImproved StrengthImproved DietMental WellbeingSport Specific (please specify)

sport:

How would you like to achieve your goals?

Faster (harder to achieve and maintain)Longer Period (more manageable to achieve and maintain)

Obstacles and ChallengesDescribe any difficulties you have encountered in your nutrition and tranining.

Nutrition

How often do you purchase groceries, either in person or delivered?

Never1 or more times / weekless than 1x / week

How often do you eat out?

NeverLess than 1x / week1 x / weekMore than 1x / week

How do you feel about cooking / preparing food?

Love it and cook for myself frequently!I make meals as requiredI don't cook

Do you make meals ahead of time?

Yes - oftenSometimesRarelyNever

Dietary RestrictionsAllergies / dislikes / definite no's

Dietary PreferencesWhat are your favourite things to eat? Healthy or unhealthy?

How often do you drink alcohol?

Never / Rarely1x / month1x / weekMore than 1x / week

Have you ever weighed or measured your food using a scale?

YesNo

Have you used a food tracking app before?

YesNo

Supplements / MedicationsPlease list all medications and supplements you are currently taking.

Fitness and Lifestyle

How often do you exercise?

Rarely or NeverLess than 1x / week1-3x / weekMore than 3x / week

Exercise TypePlease describe the types of exercise you usually do

Job Activity Level

None / SedentaryModerateHigh

Work / School SchedulePlease describe your typical daily schedule

How often do you travel?

Never / Rarely1x / month1x / weekMore than 1x / week

How many hours of sleep do you typically get in a night?

Sleep QualityRate your sleep quality from 1 (worst) to 10 (best)

Peer and family support

NoneSomeEnthusiasticHow much support do you have to follow a nutrition / training program?

Health

Medical ConditionsPlease list any medical conditions you have and whether you are being treated for them.

Eating DisordersPlease share if you are or have ever suffered from an eating disorder, and whether you have previously or are undergoing treatment.

PregnancyAre you pregnant? Have you been pregnant in the past six months? Are you planning to get pregnant in the near future?

Contact CRUSH

crushcoachlori@gmail.com

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