XCel Performance Client Intake Form

Programming Intake Form
Name*

First NameLast Name
Birth Date*

MonthDayYear
Height*
cm
Weight*
kg
Email*
example@example.com
What is your primary goal that you want to achieve working with me? Please be as specific as possible as this will allow me to tailor a program that is best suited for you.*
Do you have any other goal that you want to achieve within the next 12months?*
Which of the following statements fit in with your goals?*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Please rate your readiness to change.*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
What is your daily activity level?*

1

2

3

4

5

6

7

8

9

10

1 is None, 10 is High
What is your daily stress level?*

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
What is your sleep quality at present? *

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Do you have any previous history of training/sports? Please describe in as much details as possible. *
Do you have any limitation for training? (i.e. time, life/work commitments etc.)*
How many days/hours of training can you commit to, on your WORST week?*
Do you have any current or past injuries? (Please detail as much as possible, even the injuries you may think are irrelevant.)*
What days of the week are you going to dedicate to training?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Are you taking any medications? If yes, please list below.*
How does your current diet look like?*

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special dietCarnivore
Should be Empty:

Programming Intake Form