Emergence Fitness 1:1 Online Coaching
By Giselle Marie
New Client Intake Form
Name
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First Name
Last Name
Email:
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example@example.com
Phone Number:
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Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth:
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-
Month
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Day
Year
Date
Gender:
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Please Select
Female
Male
Height:
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Current Weight in lbs:
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Current Occupation (if in school please put student)
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Instagram Handle:
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Have you ever worked with a coach before?
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Please Select
yes
No
Do you have access to a gym facility?
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Please Select
Yes
No
What aspects of fitness do you find most challenging?
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The Gym - exercises, form, sets, what to do, etc.
Nutrition - What to eat, when , how to be prepared, tracking macros, counting calories, etc.
Mindset - feeling discouraged, not supported, no motivation, etc.
What does your daily routine look like? Share a bit about your work hours, responsibilities, family commitments, and how you spend your free time. This helps me understand your lifestyle better so we can create a plan that fits seamlessly into your day.
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What are you hoping to achieve with coaching? Let me know your main goals, any challenges you're facing, and what you'd like to work on most. For example, are you looking to lose weight, build strength, improve flexibility, or boost your endurance?
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What challenges have been holding you back from reaching your goals? This could be things like a busy work schedule, personal commitments, family responsibilities, or social obligations. Understanding these will help us find solutions that work for you.
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Fitness/Physical Activity Experience
How frequently do you engage and are committed to physical activities during the week?
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Please Select
NONE
1-2 Days a week
3-5 Days a week
5-7 Days a week
Have you done weight training before? If yes, how experienced would you say you are with it beginner, intermediate, or advanced?
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Please Select
Beginner
intermediate
advanced
What does your current workout routine look like? Let me know what types of exercises you’re doing, how often you train, and any specific focus areas.
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How many days a week can you commit to working out? And how long can each session be around 45 minutes to an hour, or more?
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Are you doing any cardio right now? If so, what type of cardio are you doing, how long are your sessions, and do you track your daily step count? If yes, what’s your average?
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How do you like to stay active? If you have a current fitness routine or schedule, could you share a quick overview of what it looks like?
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What are your health and fitness goals? Please share as much detail as you can for example, are you aiming to lose weight, build muscle, improve endurance, or enhance overall wellness?
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Current Nutrition and Supplements
How would you describe your relationship with food? For example, do you feel it's balanced, do you struggle with cravings, or do you find it challenging to stick to certain eating habits?
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Do you consume alcohol regularly?
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Please Select
Yes
No
Do you smoke tobacco?
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Please Select
Yes
No
Do you smoke or consume THC products?
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Please Select
Yes
No
Can you share a list of fats, proteins, and carbs that you enjoy eating? This will help me create a personalized meal plan that fits your preferences and goals.
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Are you familiar with tracking macros or counting calories based on your food intake?
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Please Select
Yes
No
Do you currently have a food scale? If not, I recommend getting one it’s super helpful for tracking and managing your nutrition effectively.
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Please Select
Yes
No
Do you have a weight scale at home? If not, I suggest getting one it’s a great tool for tracking progress and gathering biofeedback.
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Please Select
Yes
No
Can you share an overview of what a typical day of meals looks like for you? If you know your average calorie intake or the specific macros (proteins, fats, carbs), please include that too. Be as detailed as you can, and feel free to share openly there’s no judgment here!
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How many meals do you usually eat in a day? Also, what time do you typically have your first meal?
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Do you have any allergies or food sensitivities? Are there any foods you dislike or try to avoid? Also, have you noticed any foods that cause issues like indigestion, acid reflux, heartburn, gas, or bloating?
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Do you typically have regular bowel movements, around 1-2 times a day? Are they of normal consistency not loose or difficult to pass?
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Are you currently taking any supplements, like vitamins, minerals, creatine, glutamine, or protein? If so, which ones?
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For women only: Do you have regular menstrual cycles, and are you currently using any form of birth control? This information can help tailor your plan to your needs.
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For women only: Have you been diagnosed with any conditions like PCOS, Endometriosis, Menopause, Thyroid Disease, Cancer, Pregnancy, Disordered Eating, or other health issues that could affect your fitness journey? If so, are you currently working with a physician for treatment or management?
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Are you currently taking any prescription medications that could affect your workouts or diet? If so, please share so we can tailor your plan accordingly.
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Recovery and Stress Levels
On a scale from 1 to 5, how would you rate the typical stress level of your day?
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Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How many hours of restful sleep do you usually get each night?
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Please Select
4-5 Hrs of sleep
6-7 Hrs of sleep
8-9 Hrs of sleep
Do you have any difficulties with falling asleep or staying asleep? If so, let me know what challenges you're facing.
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Do you usually feel muscle soreness after your workouts? If so, how intense is it and how long does it typically last?
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Current Body Composition
If you’ve had a recent body scan, could you share your most recent numbers for body fat percentage and lean body mass? This will help in tailoring your plan to your goals.
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Provide a front, side, and back photo of yourself with your entire body in the frame, ensuring good lighting (Avoid mirror selfies). To capture these images, set your phone to record, assume the required poses, then screenshot each one from the video. Wear comfortable attire, with women opting for a sports bra or bathing suit top and short spandex/bikini bottom, and men wearing shorts or swimshorts/boxer briefs.
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Are you ready to make a financial commitment to yourself and your fitness goals? This program is a 3-month commitment designed to help you achieve lasting results.
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Please Select
yes
no
How soon can you start?
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Is there anything else you'd like to share questions, concerns, or important details—that I should know to help you reach your goals? Open communication is key, and I’m here to support you every step of the way!
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