Client Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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I am a
*
Male
Female
Age
*
Menstrual Cycle
*
Normal
Menopause
Not applicable
Weight (upon waking)
*
Height
*
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Exercise Routine
Daily Activity Level
*
Slightly active
Moderately active
Active
Very active
How many days per week do you do weight training?
*
0 - 1
2 - 4
4 - 7
Minutes per weight training session
*
Intensity level during weight training
*
Low
Moderate
Vigorous
How many days per week do you do cardio?
*
0 - 1
2 - 4
4 - 7
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Daily Routine
Wake Time
*
Bed Time
*
Workout Time
*
Occupation
*
Times it is difficult to consume a meal
*
Meals per day
*
List any medications that you take
*
List any supplicants that you take
*
List any injuries
*
Blood type
*
A negative
B positive
B negative
AB positive
AB negative
Don't know
Food allergies
*
Foods you love (check all that apply)
*
Healthy choices
Proteins
Carbs
Fats
Veggies
Other
Foods you dislike (check all that apply)
*
Healthy choices
Proteins
Carbs
Fats
Veggies
Other
Favorite desserts/cheat meals
*
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Fitness level
*
Extremely fit
Somewhat fit
Not fit
Have you ever worked with a nutrition coach?
*
Yes
No
Have you ever worked one-on-one with a personal trainer or coach?
*
Yes
No
What are your fitness goals (be as specific as possible)
*
Motivation behind your goals
*
Typical day's Food Log (please list what you normally eat in a day)
*
Signature
*
Please verify that you are human
*
Submit
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