Online Training Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

FemaleMale
Height
Weight
lb
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Do you have any injuries? If yes, please list below.
How does your current diet look like?

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
What sport do you play?

Baseball/SoftballFootballGolfSoccerNoneOther
Which of the following are you looking to improve?

General FitnessImproved CardioIncreased strengthIncreased muscle massFat lossOther
What are your goals?
Weight loss, strength, etc
How long of a program are you looking for?

6 week8 week
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
My Products
prevnext( X )
Sport Specific
Sport specific workout plan designed to help you improve in all facets of your respective sport.

$200.00

General Fitness
6 or 8 week program designed to help you reach your goals!

$150.00

Total

$0.00
Should be Empty:

Your Information