New Client Intake Form
Name
*
First Name
Last Name
Email (for contact only; no spam and we don't sell any of your info)
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Stepp Up Fitness?
*
Please Select
MPI
Referral from friend/family
Internet search
Social media
LinkedIn
Business card / flyer
Company / residence referral
Other
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender at Birth
*
Please Select
Male
Female
Note: We happily accept and encourage people of all gender identities to exercise with us. However there are some physical, sex-specific characteristics we need to adjust for when making our recommendations so we appreciate you supplying us with this information.
Gender Identity (if different than birth gender)
Are you taking any hormone therapy?
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Height (inches)
*
Weight (lbs)
*
What is your usual occupation?
What is your main fitness goal? (Please select just one to start - don't worry, these are not mutually exclusive!)
*
Please Select
New / returning to fitness after a break
Weight loss
Body recomposition
Muscular development
Cardio improvement
Training for an event / competition
Balance and coordination
Maintain current health
If you chose weight loss, how many pounds would you like to lose?
For initial discussion only. If you're not sure, enter 0. Your trainer will help you understand your ideal number based on your other assessments and lifestyle.
About how often do you exercise?
*
Please Select
Never worked out
One workout a week
Two workouts a week
Three or more workouts a week
How long have you been exercising?
*
Please Select
0 - 6 months
6 - 12 months
1 - 3 years
3+ years
Average Exercise Score
What is your average daily activity level (NOT including exercise)?
*
Please Select
Sedentary; little or no walking. Desk job.
Slightly active; moderate walking. Server or retail job.
Quite active; lots of walking. Warehouse worker or similar
Very active; heavy walking and lifting. Construction, landscaping or similar
Daily Activity Level Score
Would you like to enter your current weightlifting and running stats?
Yes (only select if you know them)
No (default)
List any of your maximum lifts you've achieved in the past year. Use REPSxWEIGHT, i.e. 6x150.
List your best running times (any that apply) and the month/year you achieved them.
List your cardio metrics (any that apply) and the date it was measured.
Submit
Should be Empty: