"Create Your Best Self"
Submit Your Story
The Day You're Told You're Fat
Training Services Application
This Form cannot be submitted until the missing
fields (labelled below in red) have been filled in
New Client Application
Please note that all fields followed by an asterisk must be filled in.
Bosnia and Herzegovina
British Indian Ocean Territory
British Virgin Islands
Central African Republic
French Southern Territories
Heard and McDonald Islands
Federated States of Micronesia
Northern Mariana Islands
Papua New Guinea
S. Georgia and S. Sandwich Isls.
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
St. Pierre and Miquelon
Trinidad and Tobago
Turks and Caicos Islands
U.S. Minor Outlying Islands
United Arab Emirates
US Virgin Islands
Wallis and Futuna Islands
Phone Number (required for online training FREE consult)
In Person Consult Only-Preferred times to meet
Date of birth (mm-dd-yyyy)*
Do you smoke (if you checked 'Yes' or 'sometimes') indicate below how frequently*
Are you diabetic?*
If you ARE diabetic, Type I or II?
1. Has your doctor diagnosed you with a heart condition and recommended ONLY medically supervised physical activity?*
2. Do you frequently have chest pains performing physical activity?*
3. Have you had chest pain when NOT doing physical activity*
4. Do you lose your balance due to dizziness or do you ever lose consciousness? *
5. Do you have a bone, joint or other health problem that causes you pain or presents limitations that must be addressed when developing an exercise program (i.e. osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, epilepsy, respiratory ailments, back problems, etc.)?*
6. Are you pregnant now or have you given birth within the last 6 months?*
7. Have you had a recent surgery (within the last 6 months)?*
If you marked YES to any of the previous 7 questions, please elaborate here:
Do you take any medications, either prescription or non-prescription, on a regular basis?*
If 'YES' to the above question, what is the medication for?
How does the medication affect your ability to exercise or achieve your fitness goals?
When were you in the best shape of your life?*
Are you currently physically active?*
How long have you been unhappy with your current health or weight situation?*
Less than 1 year
Between 1 and 3 years
More than 3 years
What, if anything, stopped you in the past with your training?
What are 1-3 short term goals for the next 3 months?*
What are 1-3 long term goals for the next 12 months?*
How will you feel once you've achieved these goals? Be specific.
How committed are you to making a positive physical and mental change in your life?*
1. I'll just watch other people workout on social media.
2. I'm only in it to get ready for an event.
3. I'm ready to go, I just need someone to guide me.
4. I've got good fitness and/or nutrition habits and I'm ready for the next level!
5. I'm so dialed in, people ask me for fitness advice!
Please indicate where you prefer to exercise*
Please indicate how you like to exercise*
With another person
Please indicate when you like to exercise*
What is your favorite movie or book?
When are you ready to start?*
Today! Let's do it!
Next week or next month
I'm not ready to change yet
PARTICIPANT RELEASE AND KNOWLEDGE OF AGREEMENT: I wish to participate in the exercise and online training program offered by Myhomefitnessplan. I understand there are inherent risks in participating in a program of moderate or strenuous exercise. I agree that Myhomefitnessplan shall not be liable or responsible for any injuries to me resulting from my participation in the online fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Myhomefitnessplan, its owners, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program. This Release shall be binding upon my heirs, executors, administrators and assigns. *
Client Signature (please enter full name in box to the right)*
I am at least 16 years of age.
I have read and accept the
I understand that you will use my information to contact me or send me the information I requested.
Please enter the word that you see below.