Fitness Coach Client Intake Form

Your Information

Pre-consultation form
Name*

First NameLast Name
Birth Date*

MonthDayYear
FemaleMale
Height*
cm
Weight*
kg
Phone Number

CountryPhone Number
Email*
example@example.com
Where you from

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Do you have any injuries? If yes, please list below.
How does your current diet look like?

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
YesNo
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
How often do you want to train a week?

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
How often can you train a week, with consistency?

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Which of the following statements fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossLearn calisthenicsOther
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Is there any exercises you want included in your programme?
Is there any exercises that you do not want included in your programme?
What type of resistance training you are looking for?Choose one or more

Free-weightsBodyweightMachinesOther (Ex: Kettlebells)
Where are you going to train? Ex: commercial gym
Is there any specific muscle you believe is lacking?
Is there any specific muscle you believe is over-developed?
What time you going to have your session?

MorningAfternoonEveningNight
What is the maximum a session should take?
What is the minimum a session should take?
Should be Empty:

Your Information