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Questionnaire Form
Name
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Last
Age
Gender
Email
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Phone number
Where are you located (City, State, Country)
Are you willing to commit to 6 months or more of coaching?
Why is it important for you to join Rebuild Weight loss academy?
Have you tried any previous weightloss programs in the past? If yes, please provide details.
What is your current weight, and what is your target weight?
Are there any medical conditions or allergies we should be aware of?
What is your current level of activity? (Sedentary, lightly active, moderately active, very active)?
Do you have a specific weight loss deadline?
How motivated are you to make lifestyle changes to achieve your weight loss goals ( on a scale of 1 to 10, with 1 being not motivated and 10 being extremely motivated)?
Are you willing to track your food intake and physical activity?
Are you open to sharing your progress and experiences with the group?
How did you hear about Rebuild Weight Loss Academy?
What kind of support do you expect to get from the weight loss group?
Are there any specific topics or activities you’d like to see in the weight loss group meetings?
Are there any specific topics or activities you’d like to see in the weight loss group meetings?
Any additional information we need? If no, put N/A
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GROUP COACHING
ONE ON ONE COACHING
PERSONAL V.I.P COACHING
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