Official Client Consultation Form

Client Start Up Form

Let’s make a change!!!
Name

First NameLast Name
Birth Date

MonthDayYear
FemaleMale
Height
cm
Weight
kg
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
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.
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
MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Should be Empty:

Client Start Up Form