First Name *

Last Name *

Phone *

Email *

Let us know your needs and preferences.

How can we best assist you with your fitness goals? (Check all that apply) *

Weight loss and fat reduction

Building muscle and increasing strength

Improving endurance and cardiovascular health

Enhancing flexibility and mobility

Learning proper exercise form and technique

How can we best assist you with your nutrition goals? (Check all that apply) *

Managing portion sizes and understanding serving recommendations

Improving energy levels and overall well-being through nutrition

Gaining strategies to reduce sugar or processed foods in my diet

Building a sustainable approach to weight loss or weight maintenance

Supporting a specialized diet (e.g., plant-based, keto, gluten-free, etc.)

How can we best assist you with your behavioral goals? (Check all that apply) *

Building healthy habits and routines

Breaking unhealthy or unproductive patterns

Improving motivation and staying consistent

Managing stress and emotional eating

Setting realistic and achievable goals

What was your sex assigned at birth? (This helps us tailor our services to your specific needs.) *

Male

Female

What is motivating you to make a change at this time? (Check all that apply) *

Improving my overall health and well-being

Achieving a specific fitness or nutrition goal

Boosting my energy levels and reducing fatigue

Setting a positive example for my family or loved ones

Preparing for a life event (e.g., wedding, vacation, etc.)

Addressing concerns from a healthcare provider

Managing stress or improving my mental health

Gaining confidence and improving self-esteem

Other

Other (please specify):

What timeline do you think you can commit to for making a lasting change? (Select the option that best matches with your goals.) *

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Thank you for choosing Efficient Results Visionary Enterprise as your wellness partner.