Client Intake Form

Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area Code Phone Number
Age
Height
Inches
Weight
LBS
Goal Weight
Overall health conditions: do you have any health conditions that the coach should be aware of? *
Do you have any deadlines, time crunches or events that you’d like your coach to be aware of? Any special events you want to get ready for? *
Do you have any injuries that your coach should be aware of while building your training plan? *
Do you currently take any medication your coach should be aware about? *
For your nutrition plan specifically, do you have any allergies, foods to avoid, preferences or special requests that your coach should be aware of? *
Many people want to lose weight and/or get healthy, but what’s YOUR big powerful reason WHY you want to do this? *
Do you currently have or do any of the following regularly? (check all that apply) *

Sweet tooth Eating a lot of snacks Stress eating Emotional eating Late night eating/snacking Not eating all day Eating out a lot because of not having food prepared Going to bed late because of electronic devices None of these
What do you usually struggle with the most for your nutrition? *
What do you do for work? What are your typical work hours? *
What are some challenges that your work/job will create for you along this journey? (if any) *
What parts of your current lifestyle do you feel need to change for you to get to your goals and become the person you want to be? *

Rate your experience with exercise

Beginner

Intermediate

Advanced

HIIT/ Circuit Training

Endurance Training

Bodybuilding

Cardio (any form)

Open Gym (general lifting)

What equipment do you have access to? (Check all that apply) *

Free weights (dumbbell/barbells) Gym machines (Nautilus, Precor, Cybex, etc... ) Cable weights Resistance bands Bosu balls Kettlebells TRX Suspension Trainer Stability Ball Foam Balance Pad Sliders None of the Above
On which days are you available to exercise? (check all that apply) *

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
How frequently do you have time to exercise? *

1-3 days a week 4-5 days a week 6-7 days a week Up to Coach to decide
Anything else you'd like your coach to know? Any other notes, comments, questions or concerns? *
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