Client Coaching Intake Form
Name
First Name
Last Name
Gender
Male
Female
Other
Age
DOB
E-mail
Current Weight
Goal Weight
Dietary Restrictions
Current Diet / Fitness Routine
Food Aversions
Favorite Foods / Beverages
Diet / Nutrition Goals
Fitness Goals
How often do you eat out per week?
Never
1-2 times
2-4 times
5 times or more
Do you cook w/oil?
Yes
No
Sometimes
Do you cook w/butter
Yes
No
Sometimes
Do you drink coffee?
Yes
No
Sometimes
Do you use coffee creamer?
Yes
No
Sometimes
Do you drink alcohol?
Yes
No
Sometimes
How many drink do you have per day?
How much water do you drink per day?
Submit
Should be Empty: