(Fill Out 3-Minute Form Below) Activity Level Sedentary: little or no exercise Exercise 1-3x a week Exercise 4-5x a week Daily exercise or intense exercise 3-4x a week Intense exercise 6-7x a week Very intense exercise daily, or physical job Date of Birth MM DD YYYY Height Gender Current Weight (pounds) Struggles (check all that apply) Accountability Knowledge/Information Motivation Environment Other Triumphs * Challenges you faced, achievements, etc. Habits to change or give up Fast Food Gossip Soda / Energy Drinks Texting / Phone Attention Social Media Procrastination Arguing with Parents Cheating Sugar Fried Foods Smoking Drinking Other Goal for next 3 months: Build Muscle Lose Body Fat Develop a Healthy Routine / Lifestyle Other Habits to Develop and Improve on Eating Healthy Exercising Meditating Prayer Getting up earlier Going to bed earlier Reading more books Becoming a better friend Becoming a better son/daughter Becoming more generous Taking time to relax Other Desired Weight (pounds) Name * First Name Last Name Email * Phone (###) ### #### Thank you! *Coach Malek will analyze and reply back within 24 hours!
