Intake Questionnaire

Questionnaire: All answers to these questions are personal and private. They will not be shared outside of this communication. If a question does not pertain to you- feel free to leave it blank or say N/A. The more details you give me here- the better.

1. Name and Age

Height/Weight

Email address

2. Relevant Medical History

*Please list any moves or movements that you have problems performing

a. Injuries:

b. Surgeries:

c. Heart Conditions:

3. Current Training Split (frequency, duration, intensity- just an overview):

or if you dont currently work out how many days per week are you willing to dedicate to exercise

4. Current type of gym you train out of what type of or any equipment you have access to

5. Any sensitivities when it comes to nutrition

6. Are you interested in competitive powerlifting?

*if so, what are your current maxes if you know them: Squat: Bench:

Squat

Bench

Deadlift

7. Competition or Athletic Experience Background

8. Level of Committment? 1-10

9. Do you currently take any nutritional supplements or any medications I should be aware of

10. Short term goals

11. Long term goals

12. Strong points Points that need improvement

13. Anything else I should know about you