Name *

First Name

Last Name

Phone

(###)

###

####

What is your primary goal?

Build strength and muscle

Improve energy and resilience

Manage stress and anxiety

Enhance overall wellbeing

Other (please specify)

How active are you currently?

I rarely exercise

I move a little but not consistently

I exercise 2-3 times a week

I have a structured fitness routine

What type of movement appeals to you the most?

Strength training

Walking/hiking

High-intensity workouts

Yoga

Sports

Athletics

I’m not sure yet

Other

Do you experience any of the following? (Select all that apply)

Stress or burnout

Trouble sleeping

Low motivation or fatigue

Difficulty staying consistent with exercise

None of the above

Other (please specify)

How confident do you feel about your nutrition choices?

Very confident – I eat well and fuel my body properly

Somewhat confident – I try, but I could use guidance

Not confident – I struggle with consistency and knowledge

Do you feel movement helps your mental wellbeing?

Yes, I notice a big difference

Sometimes, but I don’t always make time for it

I’m not sure, but I’d like to explore this more

Would you be interested in a personalised plan that integrates fitness, nutrition, and psychological wellbeing?

Yes

Maybe, I’d like to learn more

No, I prefer to explore on my own

What challenges hold you back from prioritising exercise and wellbeing?

Lack of time

Low energy or motivation

Uncertainty about where to start

Previous injuries or health concerns

Other (please specify)