Book with me

Let’s do this

Tell me about yourself

Please fill out the following form to book either nutrition or fitness coaching (or both!) Once I receive your submission, I’ll reach out within 48 hours with next steps. Looking forward to meeting you!

Name

First Name

Last Name

Phone

(###)

###

####

Age

Current height

Current weight

Ideal/goal weight

Body measurements (bust/waist/hips)

Occupation

What are your reasons for choosing to work with me?

How would you describe your lifestyle?

On average, how many hours of sleep do you get a night?

4-6

6-8

8 or more

On a scale from 1-10, how stressed do you feel most days?

1 being not stressed at all, 10 being extremely stressed.

Do you have any ways of managing stress?

On a scale from 1-10 how would you rate your self confidence?

1 being poor self confidence, 10 being great self confidence.

Are you able to take time to yourself to do things that either help you relax or bring you joy?

Do you currently exercise?

If currently exercising please give a description, and how much per week?

How many days per week are you willing to exercise? (30-60 minutes)

1-2

2-3

3-4

Have you had any injuries I should know about?

Approximately how much water are you drinking each day?

Do you like to cook at home?

Please give brief description of your current eating habits?

Do you have a history of yo-yo dieting or disorder eating?

How many times approximately each week do you eat out? (any meal, weekdays and weekends)

Are there any specific nutritional goals that you would like to achieve? Habits to break?

Approximately how many times per day do you eat? Meals and snacks

I understand that all information given to me is for informational purposes only and by training with JH Model Health I take full responsibility for my personal safety and any injuries that I may incur. I also understand that if I took the payment plan option, I am required to pay the amount in full over the agreed timeframe.

Yes and I take full responsibility

Book with me

Let’s do this

Tell me about yourself

JH Model Health

jane@jhmodelhealth.com