First Name *

Last Name *

Phone *

Email *

Date of birth

City

How would you describe your current fitness level? *

What are your TOP 3 health and fitness goals right now? (e.g. Weight loss, muscle gain, strength, endurance, better nutrition) *

What has been your biggest struggle or challenge when it comes to reaching your goals? *

Are there any injuries, medical conditions, or physical limitations I should be aware of? (If yes, please explain. If no, write N/A.) *

Are you currently working with a trainer, coach, or following a specific program? If yes, please desribe. *

How would you describe your current eating habits? *

Do you have any dietary restrictions, allergies, or foods you avoid? *

How many meals and snacks do you typically eat per day? *

How would you rate your hydration levels? *

How many hours of sleep do you get on average? *

How many days per week do you currently exercise? *

Do you prefer gym-based workouts, home workouts, or a mix of both? *

How much time per day and per week do you have to dedicate to working out? *

Do you have specific questions about the challenge, workouts in general, or training that you would like me to cover in my feedback video? *

How do you prefer to be coached? *

How committed are you to implementing change in your current health and fitness regimen? *

Is there anything else I should know that will help in my feedback video to give you the most value for your time?

I confirm that I will be watch the feedback video once received and I will respond to Allie Burke with a follow up message. *

I confirm

I understand that the feedback video is based on the information given in this form. The information is in the feedback video is not intended to diagnose, treat, cure, or prevent any disease. It is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. I understand results are dependent on my personal effort, consistency, and adherence to the program guidance. *

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