Core Information

First Name

Last Name

Address

Street Address

City

State

Country

Postal code

Phone *

Email *

Current Weight

Weight you feel best at in lbs.?

Height (e.g. 6'1")

Date of birth

Profession/Name of Company

Typical Work Schedule

Top Priorities

What are your top 3 personal health goals right now? (lose weight, feel more energy, reduce inflammation, sleep better, age well, etc.)

Why are these goals important to you right now? (Share what’s behind your goals — family, performance, longevity, legacy, etc.)

Physical Activity & Pain Points

What types of movement or workouts do you currently do? (Include type, frequency, and intensity.)

Any current or recurring pain or limitations?

Do you have any performance or mobility goals? (Examples: race performance, travel readiness, time with family, etc)

Nutrition Patterns

Walk me through a typical day of eating. (Include meals, snacks, beverages — be as honest and detailed as possible)

Do you follow a specific nutrition approach?

Favorite meals or go-to foods

Foods you dislike or avoid

Alcohol intake (type and how often)

How many ounces of water do you drink per day? Are you consistent with that number?

Caffeine intake (type and frequency)

Travel & Lifestyle

How often do you travel for work or leisure?

Do you frequently eat out for business or social events?

Roughly how many meals per week are at restaurants or with clients?

Do you cook at home regularly? If yes, who usually cooks?

Supplements or medications currently taken?

Stress, Sleep & Recovery

Rate your current stress levels

Low

Medium

High

Average hours of sleep per night

Quality of sleep

Great

Okay

Poor

Personal Notes & Emotional Health

Anything in your personal story I should know? (grief, loss, transitions, new relationships, etc.)

Do you feel fully supported in your health goals? (Yes / No / Not sure) If not, what feels missing?

What would success look like after 6 weeks of working together?

Preferences

Preferred way to communicate with me

Text

Email

Phone

Any of the above

Coaching style that works best for you

Direct and Focused

Collaborative and conversational

Data-driven

Supportive and motivational

Are you willing to make an investment of $1199 towards your health to work exclusively 1:1 with Jules?

yes

no

Thank you for completing this form. I’ll review everything personally and be in touch within 24–48 hours. I look forward to working with you.

By checking this box, I consent to the following:

I understand that I am enrolling in a 6-week private nutrition and lifestyle coaching program provided by Jules Hindman, Sports Nutritionist and Longevity Coach, through Eat Well Perform Well®.
I understand this program is not medical advice and is not intended to diagnose, treat, or cure any medical conditions. I agree to consult with my physician before making any major changes to my nutrition, supplement, or exercise routines, especially if I have a pre-existing condition.
I acknowledge that my personalized recommendations will be based on the information I provide, including but not limited to lifestyle habits, medical history, preferences, goals, and current physical condition.
I agree to participate fully and honestly, and to communicate any questions, concerns, or changes throughout the coaching process so adjustments can be made if necessary.
I understand that results depend on consistency and individual variables, and no specific outcomes are guaranteed.
I agree that all coaching materials, plans, and resources shared with me during the program are for my personal use only and may not be copied, distributed, or shared without written consent.
I understand that all information I share will be kept private and confidential between myself and Jules Hindman.

By checking this box, I acknowledge and agree to the following:

I understand that the Eat Well Perform Well® 6-week coaching program is a high-level, customized experience and that all sales are final.
I agree that once payment is made, there are no refunds, transfers, or credits, regardless of my participation level, personal schedule, or outcome.
I recognize that my results are dependent on my effort, consistency, and communication, and I accept full responsibility for my experience in this program.
I understand this policy is in place to respect the time, energy, and preparation invested in creating my personalized coaching experience.