Let's Get Started!

If you have any questions, I would love to help.

Your Profile Information

Your Name (required)

Your Email (required)

Your Phone (required)

Age

Gender
MaleFemale

Height

Weight

Safety Considerations

Please carefully answer the following questions, and check yes or no if the question applies to you:

Has your doctor ever said you have heart trouble?
YesNo

Do you frequently have pains in your heart or chest?
YesNo

Do you often feel faint or have spells of severe dizziness?
YesNo

Has your doctor ever said your blood pressure was too high?
YesNo

Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
YesNo

Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?
YesNo

If so, please explain

Lifestyle Questions

Are you physically active?
YesNo

What do you do to exercise?

Are you currently prescribed or taking over the counter medications that will affect your heart rate and/or blood pressure?
YesNo

Do you have any food allergies?
YesNo

If so, please list:

Do you smoke?
YesNo

Do you drink alcohol?
YesNo

How many hours do you regularly sleep at night?

On a scale of 1 to 10, how would you rate your level of stress?
(1 being stress-free)

Please describe your 3 biggest sources of stress:

Please describe the activity level of a typical day:
(sedentary, active, physically demanding, etc)

Do you travel often?
YesNo

Is anyone in your family overweight?
YesNo

Were you overweight as a child?
YesNo

Please include any other relevant information I should be aware of, or any questions you might have:

Contact Information

Our first step is a free consultation. I’m sure you have many questions, so please get in touch.

eMail:

michelle@fitandwelldaily.com

Location

I’m currently living in Paris, but am available for phone and video conferencing wherever needed.