Fitness Client Intake Form

Leia Nicole Fitness Coaching Application

Congrats on taking the first step to reaching all your goals! Please fill out this application and I will get back with you asap! The more specific and thorough you can be, the better I am able to help design the best possible program for you.
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Instagram Username (if applicable)
Age/Height/Weight
How many calories are you currently eating a day? Please include also how many grams of carbs/fats/protein you’re getting. If you are not sure, are you willing to track your food in My Fitness Pal for a week before we start a program?
What TYPES of foods do you usually eat every day (what does a typical day look like)
Have you been gaining, maintaining or losing weight over the last 3-6 months?
What have you been doing for cardio exercise the past 6 months? Please be specific (how many days a week, how long are your sessions, are you doing HIIT, etc)
What supplements are you currently taking?
Are you taking any medications or under the care of a physician for anything? If so, please describe:
What are your best/favorite body parts?
What are the areas that need the most work?
What do you like/enjoy about exercise, and what do you dislike?
How active are you outside of the gym? (are you highly active, are you in any sports, do you have a sedentary job, etc) What do you do for a living?
When was the last time you stuck to a diet? Did you see results? If no, why do you think that is?
Have you ever done a fitness program before? (like a weekly class, go to the gym, see a trainer, or use workout DVDs like P90x, etc) if so, what did you do and for how long?
Have you ever seen results from a workout program? If no, why do you think you didn’t see or maintain those results?
What do you feel you struggle with when it comes to diet and exercise? (can't find the motivation, it's too hard, don't know where to start, struggle with emotional eating/forgetting to eat, etc)
Do you ever have any chest pain, trouble breathing, knee pain, joint or muscle pain?
What are your short term goals?
What are your long term goals?
Do you have a history of eating disorders or restrictive eating?
How would you rate your overall digestion? Please list any current or past issues.
How many meals do you eat a day? If you skip meals, which ones?
Are you usually hungry between meals?
How many alcoholic drinks do you have a week? Do you smoke?
How comfortable do you feel performing strength training exercises with weights? (be specific with how much experience you have, how heavy you have lifted in the past, etc)
How comfortable do you feel with HIIT (high intensity interval training) and cardio type exercises?
Please list and describe any injuries or things I need to be aware of when I am designing your program.
Would you like workouts for at home, at the gym or both? If at home, please also list what equipment you have available to you.
Please list how many days you will REALISTICALLY workout a week (not how many days you wish you could workout) and the amount of time you can dedicate to each session.
What is your reason, your WHY for wanting to start a fitness program? What kind of results would you like to see? (example: fat loss, tighten and tone, become healthier overall, learn how to maintain a healthy weight, increase confidence and motivation, build lean muscle, have more energy, establish good habits, etc)
Are you ready to commit to keeping a food log, making lifestyle changes, and being consistent with checking in with your coach weekly? Rate your readiness on a scale of 1-10, with 10 being “HECK YEAH I AM 100% COMMITTED, FAILURE IS NOT AN OPTION” and 1 being “I AM PROBABLY NOT READY AT ALL AND NOT EVEN SURE WHY I AM DOING THIS”.
What is your timeline for achieving your goal? (12 weeks, 16 weeks, 24 weeks, 32 weeks, 40 weeks, 1 year)
What are your expectations of ME as your personal trainer and coach?
Please select the best days you can exercise.
Please select the best times you can exercise.
Please upload a couple photos of yourself so that I can get an idea of your body type

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Please upload a couple photos of yourself so that I can get an idea of your body type

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Is there anything else you would like to tell me?
Release and Acknowledgement
I hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential.

Leia Nicole Fitness/Leia Crowe has informed me that I am the only responsible party both for any and all injuries during the fitness program and incorrect information. If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform Leia Nicole Fitness/Leia Crowe immediately.
Date

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Date
Client Signature
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Leia Nicole Fitness Coaching Application

Release and Acknowledgement