Client Intake Form
Lifestyle Fitness & Nutrition Coaching
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
Male
Female
What are your primary fitness goals?
*
Lose weight
Build muscle
Increase endurance
Improve flexibility
General health
Other
How would you describe your current fitness level?
*
Beginner
Intermediate
Advanced
What equipment do you have access to?
None (bodyweight only)
Dumbbells
Resistance bands
Kettlebells
Barbell/Plates
Cardio equipment (treadmill, bike, etc.)
GYM
Do you have any current or past injuries or health conditions we should be aware of? If yes, please describe.
*
Current Supplements?
Meal Frequency
2 Meals
3 Meals
4 -5 Meals
Workout Frequency
1-2 Days
3-4 Days
5+
How long do you anticipate working together?
4 Weeks- $200
8 Weeks - $400
12 Weeks - $600
16 Weeks - $800
6 Months - $1200
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Supplement Selection
Select Supplements
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( X )
Protein Powder
High-quality whey protein powder
$
30.00
Multivitamins
Daily multivitamin capsules
$
20.00
Omega-3 Fish Oil
Supports heart and brain health
$
25.00
Total Price ($)
Additional Question 1
Additional Question 2
Additional Question 3
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