BODY BY BELINDA LO- POTENTIAL CLIENT INTAKE FORM

The first steps are to complete the below. From your questionnaire, I will decide if we can be a good fit to work together. Then, we will have a 20 minute free consult call to talk about my program more. Afterward, we both decide if we want to go on this journey together. My program is very personalized and intimate- so as a responsible coach, I want to make sure we are a good fit to go on your health & fitness journey together :-)

I understand that submitting this form is not automatic acceptance into the "Body by Belinda LO" program.

Full Name *

First Name Last Name

Email

example@example.com

Phone Number

Area Code Phone Number

Gender

Male Female

Date of Birth *

Month Day Year

Age

years

Height

Weight

Where do you live?

Do you have, or had in the past, any ED (eating disorders)?:

If you have any diagnosed health problems list the condition(s).

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

Do you suffer from diabetes, asthma, high or low blood pressure?

Yes No

if yes please list:

Are you a current cigarette smoker?

Yes No

What is your body/fitness goal?

What is your current exercise routine?

Do you have access to a gym? Or do you plan/prefer to workout from home?

If you work out from home, what equipment do you currently have?

How many days a week do you want to commit to exercising?

What is your fitness/sport experience?

Do you have a specific dietary need or food allergy?

What do you typically eat in a day?

What do you typically drink in a day?

Approx how much water in oz do you drink a day?

Do you drink alcohol? If yes, how many drinks per week?

Do you cook your own food?

How many meals do you have out per week (restaurant prepared)?

Are you able to eat similar meals for the majority of the week? (80% on plan, 20% off/free meals)

What are your favorite foods?

What foods do you not eat?

Please send front, back, side photos of yourself. Men: in boxers or shorts. Women: in sports bra/bra + underwear or bikini.

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