Coaching Intake Form
Please answer all questions to the best of your ability!
Name
First Name
Last Name
How did you hear about us?
Referral
Instagram
Google
Other
If you are a referral, please share who:
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Date of Birth:
Gender:
Male
Female
Current Weight:
Height:
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What are your goals? Check all that apply:
Weight loss/fat loss
Gain weight
Maintain weight
Build/Add muscle
Improve overall health/fitness
Remove or decrease medication(s)
Control eating habits
Physique Competition/Modeling
Other
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How often are you currently exercising?
Please Select
Never
1-2 times per week
3-4 times per week
More than 5 times per week
What exercise modalities do you participate in? (Choose all that apply)
Endurance (running, biking, swimming, etc.)
Bodybuilding
Powerlifting, Olympic lifting
CrossFit
Yoga, pilates, barre, etc.
Bodyweight, calisthenics, etc.
Walking
Other
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How would you describe the intensity of your workouts?
Able to carry on full conversation, low intensity/HR
1
2
3
4
Unable to engage in conversation, HR very elevated
5
1 is Able to carry on full conversation, low intensity/HR, 5 is Unable to engage in conversation, HR very elevated
How would describe your lifestyle outside of exercising?
Sedentary (majority of the day seated, desk job/driving all day)
1
2
3
4
Very active (manual labor, walking/running all day)
5
1 is Sedentary (majority of the day seated, desk job/driving all day), 5 is Very active (manual labor, walking/running all day)
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What is your profession?
How many hours of sleep do you average a night
Less than 5
Between 5 and 7
7 or more
Other
Rate your stress level
No Stress
1
2
3
4
Highly Stressed
5
1 is No Stress, 5 is Highly Stressed
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Have you ever had an eating disorder?
Please Select
Yes
No
I am currently struggling with disordered eating
Do you have any existing injuries or medical conditions/concerns? Please list all that apply.
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Are you on any medication(s)?
Yes
No
If yes, please explain:
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Do you drink alcohol?
Please Select
Yes
No
Occasionally
If yes, how often and what do you drink?
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Do you do any of the following? (Select all that apply)
Vape
Cigarettes
Recreational drugs
Other
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Do you eat at restaurants or fast food establishments frequently? If yes, how often and list which establishments.
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How comfortable are you in the kitchen?
Please Select
Very limited in my cooking ability - does cereal count?
I can follow recipes but don't know what to do without them
I am very confident in the kitchen
Do you have any food allergies or intolerances?
Yes
No
If yes, please list:
How often do you read nutrition labels
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
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Do you drink any of the following?
Coffee
Hot Tea
Sweet Tea
Regular Soda
Other
How many ounces of water do you consume daily?
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Where would you like to see yourself in the 90 days? (Ex: Lose 10 pounds, perform 10 push ups, fit into an old pair of pants, etc.)
Where would you like to see yourself in the next 6-12 months? Be as descriptive as you'd like and think outside of just the physical body recomposition. (Ex: Mindset, confidence, overall knowledge, decrease in medicine, etc)
Do you feel like you have any obstacles or limitations that stand in the way of reaching your goals? If so, what might they be?
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When are you looking to get started?
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How would you prefer to be contacted?
Call
Text
Email
No preference
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