ShakaPT
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Personal Information
Lifestyle & Goals
Health Assessment
Fitness & Exercise
Food Preferences
Program Selection
Personal Information
Tell us about yourself and your household
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Address
*
Gender
Please select...
Male
Female
Other
Prefer not to say
Age Range
*
Please select...
18-24
25-34
35-44
45-54
55-64
65+
How many people are in your household?
*
Please select...
Just me
2 people
3 people
4 people
5 people
6+ people
What best describes your occupation?
Please select...
Desk job/Office work
Physical labor/Construction
Healthcare worker
Teacher/Education
Retail/Service industry
Stay-at-home parent
Student
Retired
Other
What timezone are you in?
Please select...
Eastern Time (ET)
Central Time (CT)
Mountain Time (MT)
Pacific Time (PT)
Alaska Time (AKT)
Hawaii Time (HST)
Other
How do you prefer to receive feedback and coaching?
Direct and to the point
Detailed explanations with reasoning
Encouraging and supportive
Casual and friendly
Professional and formal
Have you worked with a fitness or nutrition coach before?
Yes, it was very helpful
Yes, but it wasn't effective for me
No, this is my first time
No, but I've tried other programs
What motivates you most? (Select all that apply)
Seeing progress in numbers (weight, measurements)
Feeling stronger and more energetic
Looking better in clothes
Health improvements (blood pressure, etc.)
Setting a good example for family
Competing with friends or community
Personal achievement and discipline
Stress relief and mental health
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