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Sculpted by Steph: Intake Form

Full Name

Email Address

example@example.com

Phone Number

Format: (000) 000-0000.

Time Zone

How did you hear about “Sculpted by Steph”

Section 2: Health & Well-being (PAR-Q)

This section is vital for your safety.

All information is kept confidential.

Date of Birth

Date

Please list any existing medical conditions, injuries past or present, or physical limitations

Are you currently taking any medications or supplements

How would you rate your current stress level on a scale of 1-10?1 (Relaxed) 2345678910 (Overwhelmed)

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

Please describe your typical day of eating/nutrition.

Section 3: Motivation & Goals

This section is where we find your "why."

What is your main goal for working with a Personal Trainer/Coach (example: build muscle, feel more confident, lose body fat, reduce pain)

What has been your biggest roadblock or challenge in achieving your Fitness goals in the past

Do you have a support system or someone who supports your fitness goals?

Why is this goal important to you right now? How will achieving this change your life or how you feel about yourself?

Section 4: Fitness & Coaching Preferences

This helps me build the best program and coaching style for you.

I am Interested in…

How would you describe your current fitness/activity level?

How many days per week can you realistically commit to exercise?

How much time do you have for each workout session? (In Minutes)

Where will you be doing most of your training?

Which form of accountability helps you the most?

List any Food Allergies

Is there anything else you want me to know about you, your lifestyle, or your expectations for our coaching journey?

Section 5: Declaration & Agreement

Client Signature

Date