Online Coaching Intake Form

Online Coaching Intake Form
Client Name

First NameLast Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Please state if you have current/previous health diseases/issues. Include any issues around your menstrual cycle here.
Please state whether you take any medication/supplements.
What does your current routine look like? Include any training, stressors, nutrition etc. here.

Health & Lifestyle

Rows	Yes	Sometimes	No
Do you smoke?
Do you drink alcohol?
Are you tracking your daily food intake?
If no, are you interested in tracking your daily food intake?
Do you have any pain while exercising?
Do you have or have you had any issues around your menstrual cycle?

How confident do you feel in your training at the moment?

	0	1	2	3	4	5

0 is Not very, 5 is On top of it!

How well do you feel you are nourishing your body with food at the moment?

	0	1	2	3	4	5

0 is Not the best, 5 is Fully nourished!

How often do you want to exercise per week?
Current weight? (If known)
Height? (cm)
Why do you want to start online training with PT WITH B?
Release and Acknowledgement
I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential. PT WITH B has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I release and discharge PT WITH B from any disclosure of my personal information in this PT WITH B Online Coaching Intake Form. If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform PT WITH B authorities immediately.
Date

MonthDayYear
Date
Client Signature
Should be Empty:

Release and Acknowledgement