Email
*
First and Last Name
*
Phone
*
Do you have a coach you'd like to work with?
*
Heather Rodgers
Lori Carroll
Heather Lotstein
No preference
What program(s) are you interested in?
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Fitness Coaching
Nutrition Coaching
Functional Coaching
What have you tracked before? Select all that apply.
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Calories
Macros
Other
If you selected "Other", tell us more.
What diets have you tried before?
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Keto
South Beach
Carnivore
Paleo
Weight Watchers
Vegetarian
Vegan
Optavia
GLP1
Other
Not applicable
Do you have any current medical diagnoses?
Are you taking any medications?
*
How many times a week do you lift weights (strength train)?
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1 - 2
2 - 3
3 - 4
4 - 5
5+
How many times a week do you do cardio exercise for 30+ minutes?
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1 - 2
2 - 3
3 - 4
4 - 5
5+
Not including exercise, how active are you on a daily basis?
*
Sedentary: I sit most of the day.
Moderately Active: I sit throughout the day but am often up and walking.
Active: I am on my feet and moving or lifting most of the day.
Very Active: I am constantly moving, lifting, and rarely sit down.
Approximately how many steps do you take each day?
0 - 2,000
2,000 - 5,000
5,000 - 7,500
7,500 - 10,000
10, 000 - 12,000
12,000 +
What is your age?
*
What is your height?
*
What is your weight?
*
What was your assigned sex at birth?
*
Female
Male
Other variation
If you have a goal weight, what is it? Why is this your goal?
What goals do you want to accomplish by working with M2R Wellness?
How did you hear about us?
Instagram
Facebook
Tik Tok
Client Referral
M2R gym or wellness partner
Other
As changes to your diet, supplements, and/or activity level can be strenuous, we encourage you to consult with a physician prior to engaging in any new behaviors or activity changes. By selecting "Yes" below, you acknowledge that M2R Wellness is not a medical facility and our coaches are not doctors. We will always refer to medical professionals for diagnoses and treatment plans and are happy to partner with them to ensure you receive the utmost care on your wellness journey.
*
Yes, I understand.
I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.
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