Consultation Call Intake Form

Please complete and submit this form BEFORE your initial Movement Screening/Consultation Call. The more information the better!!

Name

First Name

Last Name

On a scale of 1-5, how ready are you to make your goals a reality? (1 being not ready and 5 being ready to go now!)

Age

Gender

Height

Current Weight and/or Body Fat Percentage

Occupation

Describe your current exercise routine:

Describe your current nutritional habits:

Do you do any physical activity outside of the gym?

Describe your past exercise/nutrition habits and routines. Why did or didn't they work?

What do you want to achieve by working with me?

What are your struggles with reaching your goal?

Medical issues and/or injuries:

Do you have any pain from any exercises or movements?

How did you hear about Em-Powered Life?

Were you referred to this program by someone?

If yes,

please provide the name and number of the person.

Email Address

Phone

Country

(###)

###

####

What time zone are you in?

Is there anyone you would want to review this with before taking the next step in your journey to a healthier you?

Be sure to be in a place you’re fully present for your call with good internet/wifi. Will you be in a place where you're fully present?

Do you give consent to have your discovery call recorded for quality and training purposes?