• NEW CLIENT INTAKE QUESTIONAIRE

  • Part 1. Basic information

  • Gender

  • Part 2. Lifestyle Information

  • Whats the activity level at your job?
  • How often do you travel?

  • Part 3. Medical and Health Information

  • Are you experiencing any stresses or motivational problems?
  • Has anyone of your immediate family developed heart disease before the age of 60?
  • Do any diseases run in your family?
  • Do you suffer from diabetes, asthma, high or low blood pressure?
  • Are you a current cigarette smoker?
  • Your current diet could be best characterized as:

  • Part 4. Goals

  • Please rate your readiness for change.
  • Which of the following best fit in with your goals?
  • TImeline for achieving your goal.
    Rows
  • Please rate your motivational level to reach your goal.
  • Are you currently excersising regulary (at least 3x per week)?
  • Have you worked with a coach before?
  • At what times during the day would you prefer to train?

  • Please Read The Following Terms and Conditions

  • 1.) CANCELLATIONS

    You will be required to choose a contract that works for you. I offer month to month contract's with a minimum of a 3 month commitment to start. I also offer paid in full options that we can discuss after your consultation. There will be absolutley no refunds on services provided.

     

     

    2.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

    All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

     

  • I AGREE TO THE ABOVE TERMS & CONDITIONS!
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