New Client Intake Form

NEW MEMBER INTAKE FORM

JAMIEIANNUCCI.COM

Today's Date*

MonthDayYear

Name*

First NameLast Name

Date of Birth*

MonthDayYear

Age:*

Gender:*

MaleFemaleOther

Email*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone*

Area CodePhone Number

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Family Doctor Name, Address and Contact Number*

Occupation:*

Current Height (Feet/Inches)*

Current Weight (Lbs)*

Are you currently taking any prescription medications, vitamins, minerals, supplements or performance enhancing drugs? Please describe:

Do you have any diagnosed medical conditions such as thyroid issues, digestive issues (IBS, SIBO, etc.) heart disease, blood pressure issues, or anything else? If yes, please describe.

For women, do you experience any of the following:

Regular monthly periodsPeri-menopausalPost-menopausalOther (see below)

If other, please describe:

For men, have you had your testosterone levels checked recently? What were the results.

Do you have any food allergies or intolerance? Please describe.

What are your favourite whole foods to eat?*

(What are your favorite animal proteins, favourite complex carbohydrates, favourite forms of fat?)

Do you drink caffeine? If so how much per day and what do you add to it? (Please give measurements of things you add)

What foods do you not like, if any.*

How is your gut health? Are you regular? Gas/bloating etc?

Please provide an example of what you've eaten and drank throughout the day for the last 24 hours.*

There is no wrong answer here, be honest. This helps me understand your current eating habits so I can design a diet protocol that will be effective for you. Please list your breakfast, lunch, dinner, and any snacks in between, and what you've drank.

Anything else you want to tell Jamie that would be useful towards designing your nutrition program?

Is there any chance you are, or may be, pregnant?*

YesNo

Do you have any orthopedic issues or injuries, or cosmetic surgeries which may limit you during your exercise?*

YesNo

If yes, please describe in detail what caused the injury and how it affects you and what exercise may irritate it.

Please list any medical conditions you may have.

Has a physician ever told you that you should restrict any physical exercise? If yes, please state reasons why.

Do you smoke tobacco products? If yes, how much per day?

Do you drink alcohol regularly? Are you willing to stop?

What is your screen time like? Are you willing to monitor it?

Rate your activity level at work:*

SedentaryModerately ActiveActiveVery Active

What is your current exercise program, if any?

What is your current cardiovascular fitness level?*

How would you rate your experience with exercise?*

BeginnerIntermediateAdvanced

Do you exercise regularly?*

I have never exercised regularlyI am currently starting back on a program, I used to exercise regularly.I currently exercise regularly.

What are your current fitness goals? Be as specific as you can be.*

Please list any specific body parts you especially want to improve.*

Please check what days you can commit to exercise on (I always recommend 4-5 days).*

Please list any other physical activities you will be participating in while on a program with Jamie.

Where do you intend to exercise?*

Home GymGym Facility

If you are training at your home gym, please list the equipment you have available for use:*

Anything else you want to tell Jamie that would be useful towards designing your exercise program?

PHOTOS*

Please upload this weeks progress photos, front, side, and back. Please be sure to include your face, down to your feet. (A plain background is preferred. Ensure that you are facing the main source of light and the main source of light is behind the camera.)

Measurements (shoulders, chest, biceps, bottom rib, navel, hip bones, glutes, thighs, calves. Every 2 weeks)

CONTACT INFORMATION

NUTRITION

EXERCISE PROGRAM