tempPersonalized Exercise Program Form

Please complete the fields below. Once you submit, you’ll be redirected to PayPal to complete payment.

Name
First Last
Email
Phone
Information About You Here's what I need to get you started...
Height*
Weight*
Age*
Gender*
- Male
- Female
What is your weight loss goal?*
What have you been doing for exercise in the past three months?*
Do you have any orthopedic problems, injuries or limitations?*
List the specific fitness goals that want to attain.*
List the specific obstacles you need to overcome that could prevent you from achieving your fitness goals.*
Describe in detail hour by hour what a typical day looks like for you.*
Do you enjoy or have played any sports?*
List any people in your life you think will support you directly and how in achieving your fitness goals.*
List any people that could sabotage your success and how.*
Is there any reason you can not physically exert yourself?*
Are you on any medication? If so please list.*
Do you or have you ever had high blood pressure, heart issues, family history of heart problems, cancer, or any other diagnosed disease?*
Describe the time in your life when you felt you were the fittest. Explain the circumstances.*

Information About You Here's what I need to get you started...