Vanguard Barbell Coaching
Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Height
Weight
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
In general, what are your goals? Check all that apply.
Lose weight/fat
Gain weight
Maintain weight
Add muscle
Improve overall health
Improve physical fitness
Look Better
Feel Better
Have more energy and vitality
Healthy aging
Gain control of eating habits
Get stronger
Physique competition/photoshoot
Powerlifting competition
Improve athletic performance
Get off or decrease medications
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Of all the changes you would like to make, which are the most important and/or urgent?
Have you tried anything in the past to change your habits, your health, your eating, and/or your body? If so, what?
Until now, what has blocked you or held you back from changing these things?
Right now, how would you rank your overall eating/nutrition habits?
Horrible
1
2
3
4
5
6
7
8
9
Perfect
10
1 is Horrible, 10 is Perfect
Why?
On average, how many meals do you eat per day?
1-2
2-3
3-4
4-5
5-6
6 or more
Please list your typical meals on any given day. Be as specific as you can.
Do you have any food allergies? If so, which?
Do you have any specific foods you enjoy?
Do you have any specific foods you do not enjoy?
How many meals per week do you eat in restaurants?
0-2
2-4
4-6
6 or more
What is your weekly budget for groceries and/or meal prep?
What is your weekly budget for meals in restaurants?
Do you consume alcoholic beverages?
Yes
No
If yes, what is the average number of alcoholic beverages you consume per week? 1
1-2
2-4
4-6
6-8
8-10
10 or more
What is your weekly budget for alcoholic beverages?
Who lives with you? Check all that apply. Spouse or partner Roommate(s) Child(ren) Pet(s) Other family Live alone
Spouse or partner
Roommates
Child(ren)
Pet(s)
Other family
Live alone
Do you have children?
Yes
No
If yes, how many?
Who does most of the grocery shopping in your house? Check all that apply.
Me
Spouse or partner
Roommate(s)
Child(ren)
Other family
Who does most of the cooking in your household? Check all that apply
Me
Spouse or partner
Roommate(s)
Child(ren)
Other family
Who decides on most of the menus/meal types in your household? Check all that apply.
Me
Spouse or partner
Roommate(s)
Child(ren)
Other family
Right now, how much do the people and things around you support your health, fitness, and/or behavior change?
Not at all
1
2
3
4
5
6
7
8
9
Completely
10
1 is Not at all, 10 is Completely
Have you been diagnosed with any significant medical condition(s) and/or injuries?
Yes
No
Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?
Yes
No
If yes, please explain
Right now, are you taking any medications, either over-the-counter or prescription?
Yes
No
If yes, please explain
How would you rank your health right now?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How do you feel about your schedule and time management?
Not busy
1
2
3
4
5
6
7
8
9
Very busy
10
1 is Not busy, 10 is Very busy
How stressed are you?
Not stressed at all
1
2
3
4
5
6
7
8
9
Extremely stressed
10
1 is Not stressed at all, 10 is Extremely stressed
Please list your daily schedule/routine. Be as specific as you can.
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On average, how many days per week do you train?
1-2
2-3
3-4
4-5
5-6
6-7
On average, how much time do you spend training per day?
30 minutes or less
30-60 minutes
60-90 minutes
90 minutes or more
What is your current (or most recent) training routine? Be as detailed as possible.
Approximately how many hours per week do you do other types of physical activity? (i.e. housework, walking to work, home repairs, moving around at work, gardening, etc.)
Less than 5 hours
5-9 hours
10-14 hours
15-19 hours
20 or more hours
What other types of movement and/or activities do you do?
What movements are you most proficient with?
What movements are you least proficient with?
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On average, how many hours per night do you sleep?
4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
How easily/quickly do you fall asleep at night?
Very slowly
1
2
3
4
5
6
7
8
9
Almost immediately
10
1 is Very slowly, 10 is Almost immediately
Do you feel tired during the day? If so, when?
Do you wake feeling rested?
Yes
No
What, specifically, is your nighttime routine (before going to bed)?
On average, how long before you go to bed do you stop using electronic devices (such as laptops, tablets, phones, and/or the TV?
30 minutes or less
30-60 minutes
60-90 minutes
90 minutes or more
How soon before you go to bed do you consume your last meal?
30 minutes or less
30-60 minutes
60-90 minutes
90 minutes or more
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Do you currently take any nutritional supplements? If so, please list them here. Be as specific as you can.
If you answered yes to the above question, why do you take those specific supplements?
What is your budget for nutritional supplements per month?
Are you currently under a doctor’s care for Hormone Replacement Therapy (HRT)?
Yes
No
If yes, please list the compounds and dosages you’re currently taking each week.
Do you currently use Performance Enhancing Drugs (PEDs)?
Yes
No
If yes, please list your current (or most recent) cycle. Be as detailed as possible.
If yes, what is your monthly budget for PEDs?
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How READY are you to change your behaviors and habits?
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
How WILLING are you to change your behaviors and habits?
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
How ABLE are you to change your behaviors and habits?
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
What do you expect from me as your coach?
Pleast list any additional information here
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