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?

Other
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?
Are you taking any medications? If yes, please list below.
How does your current diet look like?
Should be Empty:

Programming Intake Form