SBM Fitness by Bri
New Client Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Where do you live? (City, State &/or Country)
*
What is your current age?
*
What is your height ?
*
What is your current weight ?
*
What Do you currently do for work & How active is your job?
*
What are your primary goals ?
*
Lose 20 lbs or LESS
Lose 20 lbs or MORE
Decrease Bodyfat
Improve Fitness
Gain Muscle
Change Body Composition
Prioritize Health/Fitness while Pregnant
Postpartum Health/Fitness
Improve my Health
Improve my self-image
Improve my relationship with food
Other
Any health issues ?
*
Diabetes
Blood Pressure
Cholesterol
Depression
Cancer
Joint Pain
None
Other
What has prevented you from achieving your goals ?
*
Guidance
Accountability
Support
Consistency
I quit on myself
I have hit a plateau
Procrastination
Poor food choices
Not enough exercise
Emotional / Stress Eating
Other
On a scale from 1-5, how ready are you to make this change?
*
1
2
3
4
5
What best describes your primary goals in the next 12 months?
*
Become the best version of myself
Improved Fitness
Get healthier
Get Toned and Defined
Feel better in my own skin
Prioritizing Pregnancy Health/Fitness
Postpartum Health/Fitness
Lose Weight
Gain Muscle
Overall Body Transformation
Change Body Composition
Lower my bodyfat %
Other
In your own words, what are your goals?
Why do you want to work with me?
This is program is only for serious individuals who are committed to their fitness, health and goals. Is this you?
*
Yes!
No :(
Anything else you want me to know?
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