Glutes by Jess
Client Intake Form
Client Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Health & Medical History
Do you have any current or past medical conditions I should be aware of?
*
Are you currently taking any medications?
*
Please list any additional vitamins/supplements you are currently taking.
*
Do you have any allergies or dietary restrictions?
*
Do you smoke?
*
Please Select
YES
NO
If yes, how often ______________________________________
Do you drink alcohol?
*
Please Select
YES
NO
SOCIALLY
Fitness & Lifestyle
How many times per week can you work out?
*
2-3 times a week
4-5 times a week
Other
Please select the best days you can exercise.
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What are your goals for training?
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Gain Muscle
Weight Loss
Stress Management
Increased Endurance
Other ______________________________________________
What does your typical daily schedule look like?
*
Can you describe a typical day of eating for you, including meals and snacks?
*
How many hours of sleep do you typically get each night?
*
How much water do you drink daily?
*
Is there anything specific you need from me to feel supported and stay accountable throughout the program?
*
Is there any additional information you think would be helpful for me to know?
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Signature
*
Submit
Submit
Should be Empty: