Client Intake Form

Client Intake Form

This intake form will provide us with an appropriate understanding of your current health and fitness levels, medical and/or structural pathologies you may have, lifestyle factors affecting your wellness, and goal management. Please fill this out to the best of your ability; it is by no means a test or a tool of judgement. If there are any questions that are unknown, please write "N/A."
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Weight (lbs)
Height (in)
Blood Pressure
If you know your blood pressure, please use the format ###/###. If you do not know your blood pressure, please write "Unknown"
If known, what is your resting heart rate?
If you need to check, gently place your left index and middle finger on your neck to the left of your windpipe and count the pulses for 30 seconds. Multiply by 2.
Do you currently have, or have had in the past, any medical conditions and/or illnesses? For example, cardiovascular disease, hypertension, cancer, etc.
Do you currently have, or have had in the past, any orthopedic injuries or issues to your body? If so, please check the area of occurrence.

Other
Please elaborate on any issues, acute or chronic, you have checked above.
If you have none of the above, please write "N/A"
How many meals do you eat per day?
What is a typical daily breakfast for you?
What is a typical daily lunch for you?
What is a typical daily dinner for you?
What is a typical snack for you?
If you do not snack, please write "N/A"
If you eat at multiple intervals during the day beyond a typical 3 meal routine, elaborate on your other meals below.
Please check all of the types of beverages that you drink during the week.

Other
Please elaborate on the amount you ingest of any beverages mentioned above.
How many hours of sleep do you get each night?
On a scale of 1-10, please rate the quality of the sleep interval selected above.

1

2

3

4

5

6

7

8

9

10

1 is Very Poor, 10 is Very High
Do you do any forms of alternative healing or movement? Please check any that you have or wish to do.

Other
Please list your primary goals here.
Primary goals are those that ideally you'd like to achieve in the next 2 months.
Please list your secondary goals here.
Secondary goals are those that ideally you'd like to achieve in the next 6 months.
Please list your tertiary goals here.
Tertiary girls are those that ideally you'd like to achieve in 1 year.
By signing here you agree that you have answered these questions truthfully and to the best of your knowledge.
Should be Empty: