7 Days - New Body, New Life

This question form will likely take you about 30 – 45 minutes to complete.  If you have interest in physical change, please invest your time and attention to being candid, thorough, and honest.  After reviewing your responses, I’ll be able to recommend what I believe is the best exercise intervention to help you find betterment.  There are several variations of my A.L.I.V.E. protocol as well as a number of books and programs I’ve created over the past 20 years.  By reviewing your information I’ll be able to make a preliminary assessment as to the program that will best serve you.

(Note: All information will be reviewed by Phil Kaplan personally and will be kept confidential unless otherwise discussed.)

  • Name *
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  • Email Address *
  • Telephone *
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  • Alternate Phone
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  • Date of Birth *
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  • Height (feet' inches") *
  • Current Weight *
  • Perceived Ideal Weight *
    This is purely subjective. If you could adjust your weight to what you believed to be an ideal, how many pounds would you weigh?
  • City (or nearest major city) *
  • State *
  • If you were referred to ALIVE by a fitness professional, who referred you (full name)?
    There are a limited number of certified ALIVE coaches throughout the U.S. If you were referred by a personal trainer and want that trainer to guide you through ALIVE, he or she must be "certified" specifically in the ALIVE training protocol.
  • Have you attended Phil Kaplan's ALIVE seminar either live or via the web? *
    Yes
    No, but I'd like to
    No, I'm not interested in the ALIVE seminar or webinar
  • OK, now we're going to get to know you. Here goes . . .
  • Describe, in a few paragraphs, your exercise history
  • What is the most pressing physical issue that makes you feel a physical change is in order *
    This should not be a list of goals, but rather ONE issue you presently find pressing related to your health and fitness
  • Describe, specifically, how your body will look and feel differently 6 months from now *
    Answer this question assuming you received everything you hoped for from the recommended program
  • Describe any physical limitations or medical concerns *
    Please be thorough, even if you feel they may not have relevance. All information will remain confidential. If, in being candid, thorough, and honest, the answer is "none," type the word NONE in the space provided
  • Describe your present or previous experience with any personal trainers *
    If you've never worked with a personal trainer, you can either share your perception of personal trainers, or simply type the word NONE in the designated space
  • Put a check next to any of the symptoms you experience occasionally or frequently
    Fatigue
    Memory / Cognitive Challenges (not as sharp)
    Emotional Stress
    Feelings of Depression
    Digestive / Stomach Upset
    Anxiety
    Headaches
    Respiratory Challenge (coughing, difficulty catching breath, easily winded)
    Ear, Nose, or Throat Issues
    Dry Skin (either localized or systemic)
  • List the medications you are presently taking or have recurring prescriptions for *
    Please include hormone replacement, anabolic steroids, corticosteriods, etc. If the answer is "none," type NONE in the designated space.
  • Use this space to provide further information related to anything already addressed
  • Describe, in a single paragraph, how you beleive others "see" you
    You can answer this based on physical appearance, mood, mannerisms, or disposition.
  • What might prevent you from sticking to a program that requires adherence six days per week?
  • Which BEST describes your present attitude toward a "new" program?
    I want to be challenged and understand the value of intense exercise
    I know if it’s overwhelming it won’t fit into my life, but I understand the importance of exercise being challenging, so my exercise commitment must be modest to be lasting
    I’ve had prior experience with exercise and have been disappointed with the results. I need a program that is comfortable, that is not too intensive, and that shows evidence of change relatively quickly to keep me connected
  • Please check each one that you feel is in line with your present way of eating
    I make frequent fast food choices I know they aren't optimal but this is what I've learned to fit into my life
    I cook, but cook for the family and rarely create healthy meals for myself
    I eat in restaurants quite a bit and realize my food choices are not optimal
    I’ve been on and off of diets for years and keep gaining and losing the same weight
    I drink the equivalent of 8 glasses of water a day
    I drink soda, fruit juice, and soft drinks frequently
    I love and crave sweets, even though I know they’re not all that good for me
    I love bread, pasta, and starches but struggle with whether or not they have a place in a healthy nutrition program
    I eat more than 3 meals a day, trying to make wise food choices, low in fat, low in sugar
    I eat less than 3 meals a day, and believe if I take in more calories I’ll struggle with weight gain
    I make organic choices whenever possible
  • It's a good idea to print or save your answers. Add any remaining comments here, then Submit
    After adding additional comments (optional), review your answers and if all is accurate, go ahead and Submit. You'll receive a personal response shortly.