Client Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Weight

Goal weight

Height

Age

Are you currently following an exercise plan?

Are you currently following a diet plan?

What are your goals if I were to work with you? What is your "why?"

What barriers or challenges do you face when it comes to nutrition and exercise? (Travel for work, family support, time, etc.)

Do you prefer to work out at home or in a gym?

Price for online coaching which includes macro meal planning and workout programming: $200/month

What history do you have in athletics, training, competitions, etc?

What do you specifically need from me as your coach? What would make our relationship as a coach and client a successful one?

Any medical or health concerns that need to be disclosed? Any current medications?

Would you be willing to have a bloodwork panel done?

Best way for me to communicate to you: text (provide number) or email?

I hereby affirm that I am voluntarily starting a course of instruction in physical fitness, nutrition coaching and/or performance training (The Activity). I am voluntarily participating in the Activity entirely at my own risk.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that I am voluntarily starting a course of instruction in physical fitness, performance training, and/or nutritional coaching (The Activity.) I am voluntarily participating in the Activity entirely at my own risk. I also acknowledge that Lori Denney is not a registered dietitian and cannot medically diagnose or treat me through this program. Any advice or coaching that I may receive should not be taken as medical advice and is not intended to diagnose, treat, cure or prevent any health problems. Nor is it intended to replace the advice of a physician. All advice is hypothetical and for entertainment purposes only. Always consult your physician or qualified health professional on any matters regarding your health.

I am at least 18 years of age and competent to sign this release. I have read and understand the contents, meanings and impact and I freely accept its terms.

I hereby intend to be legally bound for myself, my heirs, and executors and hereby waive and release any and all rights and claims for damages I might have against Lori Denney or for any injuries or losses as a result of any diet, supplementation or training advice I may receive.

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Date

Signature