New Member Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
Date
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
How did you hear about us?
Nutrition
Current Weight
Height
Age
Sex
What is your goal?
Lose Weight
Build Muscle
Athletic Performance
Body Recomposition
Improve Health
Current activity level (weekly):
Very light - almost no intentional exercise
Light - 1-3 hours of gentle to moderate exercise per week
Moderate - 3-4 hours of moderate exercise per week
Intense - 4 to 6 hours of moderate to strenuous exercise
Very intense – 7+ hours of strenuous exercise
Daily activity level (excluding intentional exercise)
Very Light – sitting most of the day (ex. desk job)
Light – a mix of sitting, standing and light activity (ex. teacher)
Moderate – continuous gentle to moderate activity (ex. restaurant server)
Heavy – strenuous activity (ex. construction worker)
Dietary Preferences
Anything
Mediterranean
Paleo
Vegetarian/Vegan
Ketogenic
Other
Lifestyle
What is your occupation?
Do you have kids? If so, how many and what are their ages?
Do you have pets? If yes, what type? How many? What are their names?
Are you currently active in any sport/exercise?
Do you have any specific hobbies or interests?
History
Do you have any prior training experience?
Did any of those things work well for you?
Did any of them not work for you at all?
Are you currently trying anything new or out of the norm (Specific diets, classes, chiropractor, etc)?
Have you ever been diagnosed with any significant medical condition(s) and/or injuries?
Do you currently have any specific health concerns, such as illness, pain, and/or injuries?
Do you currently take any medications, either over-the-counter or prescription?
Goals
Do you have a specific goal? (perform a first pull-up, body composition, gain muscle, prep for a specific event, improve health, etc...)
In an ideal world, where do you see yourself one year from today?
What do you expect from us as your coaches?
Do you have any specific questions that you would want to address in our first meeting?
Submit
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