Apply for Coaching with Steph

Full Name

Email *

Weight Loss Surgery Date & Pre-op weight (if applicable)

Current Weight *

Height *

Age *

Past Medical History *

Family history of diabetes, thyroid disease, cardiovascular disease, or obesity? *

Dieting History *

Food or Medication Allergies:

Do you have a Primary Care Provider? If so, what is their contact information? *

Does Stephanie have your blessing to contact your primary care provider if needed? *

Do you have any other medical providers as a part of your care team? *

Are you on hormone replacement therapy? If so, list dosing. *

Do you have regular periods? Please explain your average cycle. *

Are you pregnant or wanting to be pregnant? *

Do you struggle with infertility or PCOS related symptoms? If so, what interventions have you tried in the past? Please explain. *

Any major past injuries or current nagging issues? Are you medically cleared for workout? *

History of eating disorder? If yes, explain. *

Current Medications & Supplements *

Any recent bloodwork in the last six months? If so, please attach here *

How many hours of sleep do you average? Do you wake up exhausted or have midday tiredness? *

What are the main stressors in your life and what are your coping mechanisms for these stressors? *

Three & Six Month Goals: *

Current Cardio & Training Protocol? *

On average, how many steps do you take in a day? *

Do you have access to a full gym? If not, what equipment do you have access to? *

When is the last time you were on a diet and how long did it last? *

Do you track your food? Do you have any understanding of macros and how to flexible diet? *

Current macros or calorie intake (If known): *

Typical Schedule (please include anything that would prevent you from eating or exercising at a certain time): *

Anything else you feel I should know *

Please attach photos. Photos should be front, back and both sides taken in the same place/lighting each time. Avoid compression garments or loose/baggy clothes *

By clicking agree, you agree that you are seeking Stephanie's advice on your own free will and at your own risk. Stephanie is not responsible for any injuries you incur while completing programming. *

yes

By filling out this questionnaire, you are giving permission for Team LOUD to use photos for social media presentation and client testimonial. *

Yes