New Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Height
Current weight (in the morning, before eating)
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Briefly describe what you would like to achieve through working with a coach. What is your main goal? How will reaching it change your life and the lives of those you care about?
What obstacles now, or in the foreseeable future, will prevent you from reaching your goal?
Say we get things rolling, and a month from now some big change/event in your life pops up. How do you think you'll handle that with respect to your health and fitness goals?
Do you own a food scale and a body weight scale? If not, you will need to get both. The food scale should be capable of weighing in grams.
NUTRITION & SUPPLEMENTS
What does your current diet look like? Please list in as much detail as possible what you eat on a day-to-day basis. Give an estimate as to how many calories you believe you take in daily. If you know your macros, please specify them here.
What time do you typically eat your first meal? Are you able to eat at any time during the day? Does your work or school schedule allow it? If there are limitations please tell me when you may be unable to eat.
List your favorite foods. Please include foods that you don't mind eating every day.
Do you have any food allergies or sensitivities?
What are some foods you refuse to eat?
What supplements are you currently taking?
Are you currently on any PEDs or hormone replacement therapy?
FITNESS/EXPERIENCE
What is your experience with lifting weights?
What is your experience with cardio?
What does your current fitness routine involve? Please be specific and list how many days a week you work out, what your workouts involve, how long they last, etc...
What days of the week and times of the day are you able to train?
Do you track your steps? If so, how many do you typically average per day?
STRESS & RECOVERY
How many hours of sleep do you typically get?
Do you have trouble falling asleep at night? Staying asleep?
What is your current stress level on a scale of 1-5 (5 being the highest)?
INTERNAL HEALTH
FEMALES only: Are your periods regular (this does not include "pill bleeds", but only your normal monthly cycle)?
FEMALES only: Are you currently taking hormonal birth control? If so, which kind?
Have you been medically diagnosed with any of the following conditions: Peri-menopause, menopause, PCOS, Endometriosis, PMDD, Thyroid Disease, Diabetes, Anorexia, Bulimia, Cancer, or Pregnancy?
If you answered yes to any of the above, are you currently under the care of a physician? If so, what is your current treatment protocol?
Please list any medications (prescription or OTC) you are currently taking.
Have you had blood work done within the last year? If yes, please attach your bloodwork results below.
Please attach most recent lab work results here.
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Do you often experience gas, bloating, heartburn, acid reflux, or any other indigestion symptoms? If yes, please specify frequency and when it generally occurs.
Do you have regular (at least 1-2 per day) bowel movements?
Do you often feel constipated or have loose bowel movements?
Please attach a front, side, and back picture of yourself. These should be taken in good lighting - please no selfies. Bikini or short shorts/bra top for women; boxers/briefs or swim trunks for males.
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Your pictures may be used on social media for HGFIT in the form of "client progress updates" and your face and you name will NEVER be shown or posted unless you give permission. Please indicate if you prefer to stay anonymous:
YES
NO
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