TRAINING/NUTRITION - Intake Form

TRAINING/NUTRITION - Intake Form

PERSONALIZED TRAINING & NUTRITION PLANS CREATED TO HELP OPTIMIZE YOUR PERFORMANCE AND HEALTH IN AND OUT OF THE GYM. $350.00 USD - Start Up Cost. $250 Every Month After
Client Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Height ex. 5' 10"* Current Weight/Height BF % (if known) ex. 200 lbs
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
What are your primary fitness and nutrition goals?*

Health & Lifestyle*

	Yes	No
Have you undergone any surgical procedures in the past 12 months?
Are you tracking your daily food intake?
Have you played sports? High School/College/Professional
Do you experience any pain while engaging in sports/exercise?
Do you drink alcohol?
Do you smoke?
Have you ever had or currently have an eating disorder?

What is your daily routine like? What kind of work do you do? How many hours per day are you on your feet? List this for your typical workdays AND weekend days.*
What is your sleep schedule like? When do you wake and go to bed?*
Please state if you have current/previous health conditions.*
Please state whether you take any medication.*
How many times do you eat per day?*

1

2

3

4

5

6

1 is 1 Meal, 6 is 6 Meals
How may hours between each meal?*

1

2

3

4

5

6

1 is 1 Hour, 6 is 6 Hours
What is your rate for your current nutrition?*

0

1

2

3

4

5

0 is Poor, 5 is Excellent

Give me an idea of how/what you eat on an average day. Use your food intake from today if that helps.

	Meal Details
Meal 1
Meal 2
Meal 3
Meal 4
Meal 5
Meal 6

Do you take any nutritional supplements/vitamins? If yes, please list.*
Do you have any food allergies or foods you will not eat? Please list below.*
Please detail any specific nutrition requests you may have.
How many days a week can you workout?*
Please select the best days you can workout.*

SunMonTueWedThurFriSat
Please select the best times you can workout.*

Early MorningsMorningsEarly AfternoonsAfternoonsEvenings
Have you followed a training and/or nutrition plan in the past? How was your experience?*
Do you currently engage in weekly exercise or training? (Weight Train, Spin/Bike, Run, Class Workouts) Please provide a detailed explanation of your current workout schedule or routine.*
Release and Acknowledgement
Client Signature*

Powered by Jotform SignClear
I, First Name* Last Name* hereby affirm that the information provided above is accurate and complete. I am fully aware of the potential risks associated with training and acknowledge my responsibility for any undesired situations, including injuries or illnesses, that may occur during training or as a result of following the nutrition plan. I understand that the information in this form will be treated with confidentiality.

I also recognize that Keenan Polanco is not a registered dietitian or nutritionist, and any nutrition plans provided are recommendations, not personalized professional advice.

I am aware that I am solely responsible for any injuries or illnesses that may occur during the fitness and nutrition program, as communicated by Keenan Polanco. Consequently, I release and discharge Keenan Polanco from any obligation to disclose my personal information as stated in this TRAINING/NUTRITION - Intake Form. In the event of any changes in my health, lifestyle, or personal information that could impact my training, I commit to promptly informing Keenan Polanco.

I acknowledge and agree to submit a non-refundable payment of $350.00 USD to Keenan Polanco. This payment is to be made after completing this TRAINING/NUTRITION - Intake Form in its entirety and clicking 'Continue,' thereby finalizing my submission. In the event that I do not successfully complete the payment after clicking 'Continue,' I understand that I have not submitted my form, and as a result, I should not expect any plans to be delivered by Keenan Polanco.

Should Keenan Polanco be unable to deliver these plans within 21 days of my TRAINING/NUTRITION - Intake Form submission, I retain the right to a full refund of the amount paid to Keenan Polanco for these plans. In such circumstances, I commit to initiating a refund request by emailing Keenan Polanco (physiquefreakfit@gmail.com, providing eligible evidence of the plans being 21 days late or longer. Eligible evidence includes a receipt of payment indicating the date of payment and a confirmation email of form submission displaying the submission date.

I further agree not to share, disclose, or publish any of the fitness or nutrition plans provided by Keenan Polanco online or on any social media platforms or to resell them to any other individuals. These plans are exclusively for personal use and may not be distributed without explicit consent from Keenan Polanco.
Date*

MonthDayYear
Date
Please note that Keenan personally designs all plans, and there may be a turnaround time of 14 to 21 days at times. You can expect to be contacted by Keenan within 48 hours, during which you will be provided with a timeframe for the delivery of your plans.
SELECT YOUR PLAN BELOW BEFORE CLICKING CONTINUE AT THE BOTTOM OF THE FORM *
prevnext( X )
Training/Nutrition PlansPERSONALIZED TRAINING & NUTRITION PLANS CREATED TO HELP OPTIMIZE YOUR PERFORMANCE AND HEALTH IN AND OUT OF THE GYM. $350.00 USD - Start Up Cost. $250 Every Month After
$350.00

Total

$0.00
Should be Empty:

TRAINING/NUTRITION - Intake Form

Release and Acknowledgement