First and Last Name

What is your current rank?

Mailing Address (including street address, city, state, country and zipcode)

Best Phone Number

PLEASE PROVIDE YOUR INSTAGRAM HANDLE BELOW.

***NOTE: if your social media settings are set to private, our follow-up may not been seen - so please be on the lookout for a friend request from us, so we can connect ❤️

PLEASE PROVIDE YOUR FACEBOOK USERNAME BELOW.

***NOTE: if your social media settings are set to private, our follow-up may not been seen - so please be on the lookout for a friend request from us, so we can connect ❤️

Date of Birth* (include m/d/y)

Email address*

How did you hear about Body By Boss?*

Current Relationship Status:

Current Weight:*

Height:*

What's your profession? (including your schedule will help me bette understand your day-to-day and weekly routine!)

Are you within (1) hour of my location?

Are you preparing for an event?

If yes, what is the event and what is the date? (if this doesn't apply, type N/A)

Do you smoke? (either currently or previously)

Do you drink (alcohol)?
(if yes, write what kind and how often)

Do you suffer from irregular bowels or bloating? (if yes, describe how often and how long its been going on)

Do you suffer from headaches/migraines, skin issues (eczema, rashes, acne, etc), mood swings, irregular cycles, poor sleep, reliance on caffeine (coffee or energy drinks) or carb cravings/binging?

Do you suffer from energy crashes/low energy? (if yes, describe how often on a daily and weekly basis)

Explain all checked:
(write N/A if none applies)

Medications, currently taking:
(write N/A if none applies)

Major Surgeries? (If yes, please describe)

Any Allergies? (If yes, please describe)

Do you have any NECK, BACK or JOINT pain? (If yes, please describe)

How often do you workout PER WEEK?

Rate your fitness level from 0-10:
(0 = poor, 10 = elite conditioning)

Do you do any other cross-training or forms of exercise other than jiujitsu? If so, what do you do and how often?

Do you eat breakfast? (if yes, describe a typical breakfast below)

Do you drink coffee? (if yes, how many cups/ounces daily)

Do you drink water? (if yes, how many ounces/cups per day)

List any food/diet restrictions (i.e. vegan, lactose intolerant, etc; write N/A if doesn't apply)

List any foods you dislike:

How many meals do you eat per day?

How many times do you eat dairy per day (i.e. milk, cheese, yogurt, ice cream, butter)?

How many times per day do you eat vegetables?

How many times per day do you eat fruit?

List your dietary food staples (foods you eat consistently)

List (3)eating habits you would like to change:
BE AS SPECIFIC AS POSSIBLE

In a few words, how do you describe your eating?

In a few words, how do you describe your body?

In a few words, how would you describe yourself as a person?

List 3-5 of your personal CORE VALUES:
(i.e. wealth, happiness, loyalty, etc)

This program requires your undivided commitment for 8 weeks. Knowing that, how committed are you to your own transformation?

What are 3 REALISTIC GOALS you would like to achieve in these 12 weeks? Please be as descriptive as possible!

Any additional info that I should know?