Embody Health and Fitness Intake Form

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First name

Last name

Phone Number

How do you prefer to be contacted?

Text Message

Phone Call

By selecting "Text Message" above, I agree to receive marketing and service-related text messages from Embody Health + Fitness (e.g., program updates, check-in reminders, and occasional promotions). Message frequency may vary. Message and data rates may apply.

Text HELP for help or STOP to cancel at any time. View our Privacy Policy and Terms of Service.

Birthday

Month

Day

Year

Where do you live? (City, State, or Country)

Which program you are most interested in signing up for?

6 Week Custom Workout Plan: $250

12 Week Custom Workout Plan: $475

6 Week Custom Meal Plan: $400

12 Week Custom Meal Plan: $675

6 Week Custom Meal Plan & Workout Plan: $575

12 Week Custom Meal Plan & Workout Plan: $850

What is your height in inches?

What is your weight?

What is your gender?

What are your top health goals? (Lose weight, build muscle, improve energy, etc.)

How many calories per day are you currently eating?

Do you have experience in tracking macros?

Do you have access to a gym?

What is your current workout routine? (I.e. lifting, cardio, HIIT, how many days/wk.)

How many days a week do you plan to workout when starting the plan? (This affects your calorie and macros calculations)

Do you have any health issues I should be aware of?

If we are creating a meal plan for you, please list any foods you hate or food allergies:

If we are creating a meal plan for you, list your top 3 favorite healthy carbs:

If we are creating a meal plan for you, list your top 3 favorite healthy fats:

If we are creating a meal plan for you, list your top 3 favorite healthy proteins:

Coffee Preferences: (If you want coffee included in your meal plan, how do you take it? Are you open to sweetening it with a protein shake or protein powder?)

How well do you sleep at night? (Hours per night on average)

Is there anything else I should know as your coach?

What do you want to use for your Promo Code for your followers to use?

Are you okay with me sharing screenshots of your wins or progress on our social media?

Yes

Yes, but please keep my name anonymous

I have read and agree to the Waiver of Liability and Release Agreement