Thank you for signing up for our Ultimate Catholic Wellness Program!

We are excited to begin this journey with you.  Please fill out the form below, this will give us a good amount of information to begin your program.  We look forward to working with you, and showing you how to achieve better health, wellness, and a closer connection to God.

For scheduling
*Not Required
Example: Sales at a large discount store, I work Monday through Friday from 8-5, I am on my feet all day. We use this to better understand what obstacles to your program may arise.
example: 3 days per week, 2 drinks per occasion
Please list all known allergies and your reaction to each.
Such as heart problems, diabetes, etc. If so, what?
Example: Knee replacement on left knee in 2016.
Do you weight train, do cardio, etc?
Example: I do cardio on an elliptical 3 times per week and do a circuit weight training at Curves once per week.
This includes weight training, cardio, and stretching.
If at home, what will you be using, dumbbells, trx, etc. If you are going to a gym, what gym? Any other details that you feel would help us about your training location.
Once you have reached your goals, you will be able to stick to this program parameters and live a healthy happy life, this is a lifestyle change program, not a fad diet or workout program.
Health diagnosis, retirement, accident, injury, addiction, etc
What life event or events have caused changes in your health.
How will this change effect your spouse, partner, children, and/or family?
Tell me about some habits you will need help adjusting to reach your monthly goals. (e.g. fast food, smoking, alcohol, watching too much T.V. at night, etc)
Where will you be in 6 months? Where will you be in 12 months?
In the next year, when the going gets tough and you are having a hard time coming in, what can we say or do that will motivate you to get back on track?
What time do you wake up? Go to work? Eat? Go to sleep? Are you on your feet all day? Watch much TV? etc.
Please write down what you would eat on an average day, include all meals, snacks, and beverages.
Health, cultural, religious, or other.
This includes fast food
Healthy or not