strength & nutrition details

health pulse intake form

After completing the form below you'll be directed to a scheduling page to book your free discovery call

First Name *

Last Name *

Email *

Mobile Phone *

Address

Your Home Street Address *

City *

State *

Country

Postal Code *

Date of Birth *

Gender *

I consent to receive infrequent SMS notifications from Modus. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Release of Liability

I have enrolled in a program consisting of physical activity including, but not limited to, walking, running, weight lifting, and the use of various conditioning and exercise equipment. I hereby affirm that I am in appropriate physical condition and do not suffer from any disability that would prevent or limit my participation in this program. I UNDERSTAND THAT PARTICIPATION IN THIS PROGRAM INVOLVES INHERENT RISKS OF INJURY, AND I FREELY AND VOLUNTARILY ASSUME ALL SUCH RISKS. In consideration of my participation in the program, I, FOR MYSELF, MY HEIRS, EXECUTORS, AND ASSIGNS, hereby RELEASE, WAIVE, AND COVENANT NOT TO SUE New Vision Strength and Wellness LLC (d.b.a. Move with Modus) and its owners, employees, contractors, and agents from any and all claims, demands, or causes of action arising from my participation in the program or from any use of the conditioning and exercise equipment and facilities.

I hereby release New Vision Strength and Wellness LLC (d.b.a. Move with Modus) and its owners, employees, contractors, and agents from any and all liability now or in the future, including but not limited to medical expenses, lost wages, pain and suffering, that may occur by reason of heart attacks, muscle strains, pulls or tears, broken bones, shin splints, heat prostration, knee/lower back/foot injuries, and any other illness, soreness, or injury, however caused, whether occurring during or after my participation in the program or use of the conditioning and exercise equipment and facilities, REGARDLESS OF ANY ORDINARY NEGLIGENCE on the part of New Vision Strength and Wellness LLC (d.b.a. Move with Modus). I UNDERSTAND THAT BY SIGNING THIS DOCUMENT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE, AND I ATTEST, ACKNOWLEDGE, AND AGREE THAT I AM SIGNING IT FREELY AND VOLUNTARILY AND INTEND TO BE LEGALLY BOUND BY ITS CONTENT.

I acknowledge that the content provided to me during this program is for educational guidance and informational purposes only and is not intended as medical advice, diagnosis, or treatment. It is not provided by a licensed medical professional, and nothing shared through this program, its materials, or communications should be interpreted as a substitute for professional medical advice, diagnosis, or treatment. I UNDERSTAND THAT I SHOULD ALWAYS CONSULT WITH A QUALIFIED HEALTHCARE PROVIDER REGARDING ANY QUESTIONS OR CONCERNS ABOUT MY HEALTH, MEDICAL CONDITIONS, OR MEDICATIONS.

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Additional Personal Information & Training Preferences

Your Current Weight

Your Height

Which of the following training goals are most important to you?

Select all that apply

Which of the following fitness outcomes are most important to you?

Select all that apply

How often are you able to workout per week?

Where will you primarily be working out?

If you have a home gym, please list all equipment you have access to?

Diet Information & Health History

Describe your current diet

Do you have any diagnosed health issues? If so, please describe.

Do you suffer from any current or past injuries? If so, please describe.

Please provide details regarding all prescription and non-prescription medications you take, as well as any supplements you currently take.

Describe your work / life schedule

What is the quality and quantity of your average night’s sleep?

How do you manage stress?

Do you have normal, daily bowel movements?

Yes

Do you frequently experience gas or bloating?

Yes

Do you suffer from acid reflux?

Yes

Goals & Desired Outcomes

How do you feel a coach can help you meet your goals?

What does success look like for you over the next 90 days?

When was the last time you had your bloodwork drawn?

How did you hear about Modus?

Next Step

Schedule a meeting?

client transformations

real clients. real results.

"Working with Modus has been a huge unlock for me physically as well as professionally. I feel better than I have in years and my focus and energy have given me a new gear."

David Stacks

"I signed up after my dr. said I was pre-diabetic and needed to consider statin drugs. After a months I feel like I'm ten years younger and my dr. gave me a clean bill of health ."

Jaxon Bellis

"Losing weight has always been hard for me. My Modus coach made understanding nutrition easy to grasp. I'm down nearly 40lbs. I don't think I could have ever done that on my own. "

Rob Davidson

real solutions to your biggest challenges

how can modus help you?

weight loss

optimize nutrition

muscle mass

lower inflamation

injury recovery

building muscle

improve libido

improve sleep

heart health

restore gut health

increase energy

Leading Well

A Note from our founder

Anthony Diehl

Helping others overcome metabolic issues that keep them from living the healthy and strong life they want to live is my passion! Enabling other men to get healthy at the cellular level so that they can lead their families and businesses with more energy and focus is what Modus is all about.

Here is how Modus is helping men like you:

restoring energy levels & renewed focus
clarity to manage your health & fitness with confidence
accountability & habit transformation
a more capable body to serve your loved ones