Intake Questionnaire
New Client Info
Name
*
First Name
Last Name
Email
*
example@example.com
Country and City of residence
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Height (specify cm/feet)
*
Weight (specify lbs/kg)
*
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Do you know how to track macros?
*
Yes
No
I have minimal experience
What tracking app do you use?
Current macro intake (P/C/F)
When was the last time you dieted?
Rate how successful your last diet was
1
2
3
4
5
Please provide detail on your previous diet - what results did you get? Did you find it difficult or easy? How did you manage to maintain progress after the diet?
Please list your favourite, and most commonly eaten sources of Protein, Carbohydrates and Fats.
Current amount and form of cardio activity?
Ave number of steps per day?
Current Training Split - days and body parts
How long does a typical training session last?
What time of day do you usually train?
Hour Minutes
AM
PM
AM/PM Option
Please specify any injuries current/past I should be aware of.
Have you competed before?
Yes
No
If so, what level have you competed at?
Novice
Regional
National
Pro
N/A
Please summarize your short and long term goals as succinctly as possible.
*
Current list of medications
*
Current list of health/sports supplements being used
*
List all PEDs currently/previously used with dosages.
*
Any other medical/health considerations?
*
Picture from front (use relevant posing suit OR bikini for females / boxers for men)
*
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Picture from back
*
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