Individual Form | Bloom Lab

First name

Last name

Email

Phone

Age Ranges

20-29

30-39

40-49

50+

Time Zone

Occupation / Industry

Typical Work Schedule (hours or shift types)

How would you describe your work-life integration?

Balanced

Manageable but stressful

Burnout prone / overwhelmed

How would you describe your current fitness level?

Beginner

Intermediate

Advanced

What types of exercise or movement do you enjoy most?

Do you have any injuries or medical conditions I should know about?

What equipment do you have access to?

None

Dumbbells

Gym

Other

How would you describe your current nutrition habits?

Structured plan

Intuitive eating

Need guidance

Do you experience energy fluctuations related to your cycle or hormones?

Yes

No

Not sure

Interested in learning more about cycle syncing

How many hours of sleep do you typically get?

What are your top 3 goals right now? (e.g., build strength, improve posture, increase energy, manage stress)

What's been holding you back from reaching these goals?

How do you want to feel at the end of a program?

Why is now the right time to invest in yourself?

Preferred communication style

Text messages

Video feedback

Email

Phone call

What motivates you most?

Accountability

Education

Encouragement

Challenges

Ideal session time

Morning

Afternoon

Evening

I I acknowledge that Bloom Lab Fitness coaching programs involve physical activity. I have consulted my physician before beginning this or any exercise or nutrition plan, and I release Bloom Lab Fitness from liability related to participation.

I agree to the above statement.

What's one thing you'd love to accomplish in the next 30 days?

How did you hear about Bloom Lab Fitness?