Synergy Fitness Solutions
Client Intake Form - Be as detailed and specific as possible.
Date of Birth:
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Month
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Day
Year
Name
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First Name
Last Name
Email
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example@example.com
Height
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Current Weight
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Gender
*
My Main Goals are Focused Around
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Weightloss
Muscle gain
Strength gain
Athletic performance
Other
Activity Levels at Work and Hobbies You Enjoy
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What would you like to accomplish during this plan?
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What do you eat and drink (including alcohol) on a regular basis? Please include foods and drinks you most enjoy as well as some that you do not like at all.
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Do you have any food allergies or intolerances? If yes, list below.
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Do you take any supplements or vitamins? If yes, list below.
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**Please include both over the counter and prescribed if possible.
Do you have any concerns with your current eating habits? If yes, explain below.
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Do you have any barriers to healthy eating or changing your eating behaviors? If yes, explain below.
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How often do you exercise per week? Do you have access to a gym? What types of training do you enjoy? How many days per week would you be able to exercise while on this plan?
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**Be as specific as you are comfortable with, as many clients battle both eating disorders and body dysmorphia
Anything Else I Should Know?
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**Limitations, disabilities, PED's, Foods/snacks that are non-negotiables you want built into your plan.
Submit
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