Free weight loss consultation

Personalized Questionnaire Form

Thank you for allowing me the opportunity to help you achieve your weight loss and fitness goals. The purpose of this initial consultation is to help me understand your particular needs and goals and to explain in detail about how my services can help you as an individual. For example, how much weight you can expect to lose, the type of program I will design for you, and so on. Weight loss is a serious issue because it concerns your health. If you do something wrong it could cause irreversible damage to your metabolism, thyroid, and entire system. I take my job very seriously and I make sure you as my client will get the very best in care when it comes to designing you a program and providing the necessary support you will need throughout your entire weight loss journey. The initial consultation is very simple. Fill out the form below and I will be emailing you within 24 hours.

You will soon see why my personalized program has been rated one of the top weight loss and fitness programs in the Country by many fitness magazines and news media agencies. I care about you as an individual and soon you will see the difference it makes.

Johnnie D Jackow Sr - Online Fitness Trainer
Certified Fitness Expert/Author

NOTE: Your participation does not obligate you in any way, and all information submitted is kept strictly confidential.

Basic Questions - Step 1 of 5

I am a

Age

Height

Current Weight

Goal Weight

Waist Size

Optional

Please select your body-type

Pear shaped - Most of your weight is carried on the hips, buttocks, thighs, and lower waist.	Apple - Most of your weight is carried in the mid-section (Lower waist up to Chest)
Hourglass - Your weight is equally proportioned on the Upper and Lower body.	Ruler - Your weight is equally proportioned on the upper, mid-section, and lower body.

Health Questions - Step 2 of 5

I consider myself to be in

Please explain any health problems

Please explain any physical limitations you have

Are you currently under a physicians care

Yes

If yes, please explain

Misc. Health Questions - Please check all that apply

I smoke cigarettes	Job requires no activity	I am pregnant
I gain weight easily	I have had children	I am breast feeding
Nervous Disorder	Sleep Apnea	Severe Fatigue

Are you currently taking any prescribed medications

Yes

If yes, please explain

How many hours per night do you sleep

Eating Habits - Step 3 of 5

I eat green and/or colored vegetables

I eat starchy foods - breads, potato, rice, pastas

I eat chicken, turkey, etc.

I eat red meats - steak, beef, etc.

I eat seafood - fish, salmon, shrimp, tuna, etc.

I eat fresh fruits -

I eat sweet foods - cake, candy, ice cream, etc.

I drink coffee

I drink sodas

I drink diet sodas

I drink liquor

I drink beer

I drink wine

I drink plain water

Most of the meats I eat are

Most of the vegetables I eat are

Most of the fruits I eat are

Please list any natural supplements or herbs you are taking

Physical Activity - Step 4 of 5

I consider myself to be in

Do you currently exercise

Yes

If yes, please list the type of exercise below

On a scale of 1-10 with 10 being the greatest, how would you rate your exercise experience.

1 2 3 4 5 6 7 8 9 10

On average, how many days per week do you currently exercise

When I design your program how many days per week will you be able to exercise

On the days you chose above how much time will you have to dedicate to exercise

On average, what time of the day will you be able to exercise

Additional Comments

Customized Program Contents
Please select everything you would like included in your customized program

Custom Home & Gym Workout
Custom Gym Workout Only
Custom Home Workout Only

For optimal fat loss resistance training and aerobic exercise should be chosen for your workout. Please choose any extras that you would like included in your workout program.

Resistance training & Aerobic Exercise
Resistance training only
Aerobic exercise only
Fitness/Balance Ball Exercises
Stretching Exercises
Swimming Pool Exercises
Deep Breathing Exercises

Choose Your Diet Plan

I will design a diet program that I feel will work best for you based on this questionnaire form. However, I can base your program on any of the below diets. Please select one if you like (optional).
Vegetarian
Low Carbohydrate
High Protein
Quick Fat Loss
Healthy Plan
Other - Please explain below▼

Your diet plan will be tailored to fit you. NOTE: Rather than eating 2 or 3 larger meals per day, in most cases 5 small meals per day is optimal for fat loss. Please choose a meal plan below based on your current time schedule.

2 meals
3 meals
4 meals
5 meals
6 meals

Please choose any extras you would like included with your customized diet program.

Food Recipes
Special eating instructions when dining out
Internal/Colon cleansing detox program
European Body Wraps - instructions on how you can make body wraps in the comfort of your own home. Lose inches, tighten skin, flush out toxins and help smooth out cellulite.

Basic Information - Step 5 of 5

Name
Email
City
State

When I achieve my goals you can use me as a Success Story
A different name will be used to protect your identity

Yes

Completed

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