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TAFIQ'S METABOLIC SCREENING APPLICATION
 
I'm looking for women and men over 40 who want to reverse mid-life weight gain and poor health. If this is you, then please fill out the form below. All eligible applicants will be contacted by phone.

Name?

Email?
 
 
 
 
 

Mobile Phone?

Age?

Timezone

What is the number one health and fitness goal you’d like to achieve in the next 12 months?

Are you currently suffering from any hormone or metabolic imbalances that you are aware of (i.e. adrenal, thyroid, digestive disorders,menopause, andropause, pituitary, etc…)? 

Yes
No
Not sure

If yes, please explain:

Are you willing to commit to exercising a minimum of 3 times per week?

Yes
No

Are you willing to commit to changing the way you eat to reach your goals?

Yes
No

What is your monthly budget for your health and wellness?  

$1199-$1499/mo
$899-$1199/mo
$599-$899/mo
$299-$599/mo

Have you invested in your health and fitness in the past?

Yes
No

Do you have a 4ft x 6ft space to perform home workouts?

Yes
No

Do you have any injuries or illnesses that would prevent you from doing home workouts? If yes, please explain.

What type of custom coaching are you most interested in? 
1–to-1 custom coaching ONLINE
Small group custom coaching ONLINE
ONLINE + IN-PERSON custom coaching combo
1–to-1 custom coaching IN-PERSON
Why is now the time for you to transform your health and fitness?
On a scale from 2-10 (10 being “LET'S DO THIS”) where are you when it comes to being ready to transform your health and fitness right now?
2
4
6
8
10

 If you are not at a10, what would it take to get you to a 10?

Anything else you’d like me to know?

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