Coaching Intake Form

Coaching Intake Form

Welcome to the First Step!
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleNon-binary
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Are you currently taking any medications?

YesNo
If yes, then please indicate the medication name and the purpose below (state ‘do not wish to disclose’, if you want to keep this private):
Do you have any health condition(s) that you would like to share?

YesNo
If yes, then please share below:
How many days a week can you workout?

2345
What are your Top 3 goals?
What lifts do you feel need technical assistance?
Do you have any competitions coming up, please list with dates:
Do you have any current or past injuries?
What does your current programming/activity level look like? Be specific:
What does your current nutrition/diet look like? Be specific:
AGREEMENT/REMINDERS: I understand that all information I entered in this form will be considered strictly confidential.The data gathered from this form will only be used as a basis for the type of coaching/programming the client will need. I understand that in order to be successful, it is vital to follow the plan agreed by both the coach and the client.
How did you find out about our services?

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