12 week Messe Middle program
Please answer the questions as honestly as possible. Go with your gut, there is no right or wrong answers. The more information I have the more I understand how we can work together.
Name
First Name
Last Name
Tell me more about yourself.
Email
example@example.com
Phone Number
-
Area Code
Phone Number
What is your preferred way for me to contact you
Phone call
Email
Video chat
Text
Where did you find out about me?
Facebook
Instagram
Through a friend
Other
If you said other, please let me know where?
In general, what are you goals (tick all that apply)
Lose weight
Add Muscle
Feel fitter
Get leaner
Get stronger
Feel confident in yourself
Have more energy
Sleep Better
Have better eating habits
Get control of snacking habits
Stop the dieting way of thinking
Be able to enjoy life
Keep up with the kids
Stop yo-yo dieting
Please tell me about your concerns about your health, eating habits, fitness, and/or body. *
Which of these do you feel are the most important. Please prioritise 1-3 only
What is it about these concerns that make them so important to you?
Have you tried anything in the past to change your habits, your health, your eating, and/or your body? (if so what?)
If so, have any aspects of them worked and if so which ones?
Which parts didn't work for you? Why do you think that is?
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Have you already made changes to your habits, your health, your eating, and/or your body recently? How is this going for you?
Until now, what has blocked you or held you back from changing these things?
Are you regularly active in sports and/or exercise?
Yes
No
If yes, typically how many hours per week do you exercise?
N/A
1hr
2hr
3hr
4hr
5hr
more than 5hrs
What types of sports and/or exercise do you typically do?
How would you rate your fitness level
Not good
Could be better
Good
I'm on fire
Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
Yes
No
If yes, please give more details
How many hours do you typically sleep per night
less than 6hrs
6-7hrs
7-8hrs
9+ hrs
How stressful is your life on a scale 1-10 (Reply on an average week. Scale 1- no stress, 10- I cannot cope with life at the moment)
How do you typically deal with stress?
In an average week how would you rate your energy levels (1- no energy; 10-energy in abundance)
1
2
3
4
5
6
7
8
9
10
Why did you rate your energy levels the way you did and what do you do to help increase it?
On a scale of 1-10 (1-not at all, 10 – Lets go) how ready are you for change?
What does success look like for you?
Have you worked with a coach before? If so what worked well & what didn’t?
Do you have any questions you would like to ask me?
Submit
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