Client Intake Form
Basic Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Height & Weight
Occupation
Current season of life
Are you currently a mother?
Yes
No
If "yes", how many children do you have & what are their ages? Write "N/A" if this does NOT apply.
Which best describes your current season?
New to fitness
Returning to fitness after a break
Postpartum rebuilding
Currently active and wanting more structure
Training for performance or a specific goal
Looking to improve health and consistency
Other
Your goals
What are your main goals right now?
Build strength
Lose body fat
Build muscle
Improve confidence
Increase energy
Improve nutrition habits
Create consistency
Return to fitness after pregnancy
Improve athletic perfomance
Train for an event
Improve relationship with food
Other
Please explain "other"
What would you like to accomplish with coaching?
Why is this goal important to you right now?
What does success look like for you 3-6 months from now?
Fitness, lifestyle and training
Have you strength trained before? If "yes" please explain your experience, duration, previous or current routines, and anything you like or dislike.
How many days a week can you commit to training?
2
3
4
5+
H0w much time do you typically have?
30-45 minutes
45-60 minutes
60-90 minutes
Where can you train?
Gym
Home
Combo
Nutrition
How would you describe your current nutrition habits?
I feel confident with my nutrition
I struggle with consistency
I eat on the go often
I struggle with meal planning
I struggle with overeating/snacking
I don't know where to start
Are you currently tracking your calories or macros?
Yes
No
I typically require macro tracking because it helps us learn about food and get lasting results. Are you good with learning how to track your food?
Yes
No
I'm open to it, maybe.
Have you ever experienced or been diagnosed with an eating disorder or struggled with disordered eating?
Yes
No
If yes, please share anything you feel comfortable sharing so I can better support you.
Describe what a typical day of eating looks like, what your biggest challenges are when it comes to nutrition and if you have any allergies or intolerances or any :
Health & wellness
Do you currently have any injuries, medical conditions or physical limitations? If "yes" please explain.
Rate your energy levels 1-10
Rate your stress levels 1-10
How many hours of sleep do you typically get?
Are you currently taking any medications, supplements, or receiving any medical treatments that may impact your health, nutrition, or training?
Yes
No
If yes, please explain. Please share anything you feel is important for me to know so I can better support you and create a safe, personalized plan.
Pregnancy & Postpartum (Please complete if you are currently pregnant, recently postpartum, or have experienced pregnancy.)
Are you currently pregnant or postpartum? Please explain.
How many pregnancies have you had? When was your most recent?
Delivery type(s):
Vaginal birth
C-section
Are you currently breastfeeding? If "yes" please explain how your journey is going so far and how long it has been.
Have you experienced any of the following?
Diastasis recti
Pelvic floor symptoms
Urinary leakage
Pelvic pain
Pain with movement
C-section discomfort
Abdominal pressure/coning
None
Other
Have you been cleared by your healthcare provider to begin exercise?
Yes
No
Are there any postpartum concerns or goals you would like support with?
Coaching Style & Accountability
What do you need most from a coach?
Accountability
Education
Encouragement
Structure
Motivation
Someone to help me stay consistent
What has been your biggest obstacles in reaching your goals in the past?
Initial Assessment Photos
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Faith and Values
My coaching is deeply rooted in my relationship with Jesus Christ and the belief that our bodies are gifts meant to be cared for with intention and gratitude.I feel especially called to serve Christian women who know that everything is meant to be done with Him and if it is not it bears no real fruit. I will welcome anyone who feels encouraged. Would you feel comfortable with faith naturally being part of your coaching experience?
Yes, I am a Christian too. I would love faith based encouragement and support.
No, I would just prefer fitness coaching.
Are there anythings you would like me to consider to support you through your journey?
Scope of Practice & Client Acknowledgment
By submitting this form, I acknowledge that Amiah Walker is a Certified Personal Trainer and Fitness Coach, not a physician, medical provider, registered dietitian, or licensed healthcare professional.The services provided are for fitness coaching, strength training, and general nutrition education purposes only. Coaching does not diagnose, treat, prevent, or cure any medical condition, injury, or disease and does not replace medical advice, treatment, or guidance from a qualified healthcare professional.I understand that I am responsible for communicating any health concerns, injuries, pregnancy-related concerns, postpartum concerns, or limitations that may affect my ability to safely participate.I understand that results vary based on individual circumstances, consistency, effort, and lifestyle factors.
I acknowledge and agree to the above statement.
Signature
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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