Intake Form

Name

First NameLast Name

Age

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

What are your top 3 weight loss or health goals, rating them in order of importance.

Please explain why these top 3 are the most important:

What do you expect from me, as your health coach?

Have you tried anything in the past to change your habits, health, eating, or body?

If yes, what?

How many hours do you contribute to structured exercise per week?

How many hours a week do you do other types of physical activity?

What does your fitness program consist of currently?

If you have children, please list the number of children you have and their ages:

How supportive is your work place, friends or extended family of your health goals on a scale of 1-10?

How many meals do you eat a day?

How many snacks do you eat a day?

How many drinks besides water, black coffee and unsweetened tea do you drink a day? (This would include, soda, juice, sweetened tea and lemonades, alcoholic beverages and any other sugary beverages)

Do you have any dietary restrictions or allergies?

How much time are you willing to dedicate per week to meal planning, exercise and self-care?

What is your typical stress level on an average day?

On average, how many hours of sleep do you get per night?

How do you normally cope with your stress?

How READY are you to change your behaviors and habits?

How WILLING are you to change your behaviors and habits?

How ABLE are you to change your behaviors and habits?

Thank you for completing this form. Your responses will guide our approach to help you achieve your weight loss goals successfully!

Disclaimer

Please recognize that it is your responsibility to work directly with your healthcare provider before, during, and after seeking nutrition or fitness consultation. Any information provided is not to be followed without prior approval from your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

Financial Terms

All payments made for coaching products and services are non-refundable.

By signing this form, you agree to be coachable and follow all instructions provided by your weight loss coach.

Electronic Signature Disclaimer

By signing this form electronically, you agree that your electronic signature is the legal equivalent of your handwritten signature. You affirm that the information provided is accurate to the best of your knowledge. You also acknowledge that submitting this form electronically constitutes your agreement to the terms and conditions set forth by Shape Shifters.

Signature

Date