FLEXIESTHENICS INTAKE FORM
This questionnaire helps me understand your current eating habits, preferences, and goals — whether you want to lose weight, gain muscle, improve energy, or just feel healthier overall.
Privacy Note:This information is only gathered to create an accurate plan tailored to your needs. It will be kept strictly confidential and used only for professional purposes.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
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Month
-
Day
Year
Date
Age
Gender
Height
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Weight
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1. What are some of the foods or eating habits you rely on most, even if you suspect they might be working against your energy, clarity, or progress?
Fast food / fried foods
Sugary snacks / desserts
Processed or packaged meals
Caffeinated drinks (coffee, energy drinks, soda)
High-carb foods (white bread, pasta, rice)
Large portion sizes / overeating
Skipping meals or irregular eating times
Emotional or stress eating
Other
1a. please specify (other)
2. Are there any foods, or ingredients you can’t stand or absolutely avoid?
Gluten
Dairy
Soy
Nuts
Nightshade
Other
2a. please specify (other)
3. Do you follow any particular way of eating?
Plant-based
Pescatarian
“I eat whatever I want”
“Frequency Metabolism
Other
3a. please specify (other)
4. What are your primary health or wellness goals right now?
Lose weight
Build muscle
Reduce inflammation
Improve digestion
Other
4a. please specify (other)
5. Please describe any medical conditions, allergies, medications, or supplements that might affect your food or digestion.
6. What are your biggest challenges right now with food, energy, or consistency?
7. On a scale of 1 to 10, how would you rate your energy most days?(1 = Exhausted all the time, 10 = Unstoppable)
8. Which service(s) are you interested in?
Nutrition only
Mobility/Movement only
Both Nutrition and Mobility
Information only (please specify in next question)
8a. If you selected “Information only” in the previous question, please specify your question or concern here:
9. Optional Upload (if using a form) Want to show me what a typical day of eating looks like? You can upload a food pic, grocery haul, MyFitnessPal screenshot—anything helpful. 📌 Why? Some uploads will save us time and help you feel seen.
Browse Files
Drag and drop files here
Choose a file
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10. How do you prefer to be coached? (Choose all that apply)
I need hype. Keep me encouraged!
Be real with me. Tell me what’s not working.
Give me structure and a plan to follow.
I like freedom. Just give me tips I can use.
Other
10a. please specify (other)
11. Please list any injuries, tweaks, or physical limitations we should be aware of that might affect your mobility or exercise.
12. Are you currently taking any supplements or over-the-counter medicines that might affect your nutrition or physical performance? If yes, list below.
yes
no
Type a question
13. Do you have any other questions or concerns not covered in this form? Please enter them below:
Thank you! You’re messing with Flexiesthenics now — so get ready. It’s UP from here. We’ll review your answers and get back to you ASAP. God bless you and have a most awesome day.
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