Program Request

Please fill out this form completely and accurately

This information is essential to helping Stefan develop a program that addresses your needs, goals, interests and is safe and effective.

All information received on this form will be treated as strictly confidential.


    What is the activity level?

    Do you work:

    How often do you travel?

    Do you suffer from diabetes, asthma, high or low blood pressure?

    Are you a smoker?

    Your current diet could be best characterized as:

    How often are you willing to train to reach your goal? (days per week)

    Please rate your motivational level to do what it takes to reach your goal

    Are you currently exercising regularly (at least 3x per week)?

    Would you go to the gym for your workouts or will you exercise from home or any other venue?

    Your full body pictures:

    All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

    I agree to Terms and Conditions.