Tier 2 Client Intake — Functionally Fitness
Multi-page client intake form for Tier 2 coaching. Fill out all sections so your program, weekly session, and onboarding can be set up. Follow the screening instructions and the exact wording provided.
Contact & Basics
Full Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Biological Sex
*
Male
Female
Military / Service Status
Active Duty
Military Spouse
Veteran
Civilian
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
Goals
Primary training goal
*
Please Select
Build strength
Build muscle
Lose fat
Improve general fitness and health
Improve athletic or job performance
Return to training after injury or time off
Improve mobility and reduce pain
Other
Secondary goals
Build strength
Build muscle
Lose fat
More energy
Better mobility
Reduce or manage pain
Improve endurance
Improve sport or job performance
Build a consistent habit
Other
ACFT preparation details (most recent total score and any remembered event scores)
Specific event or deadline you are working toward
What would make this program a success in 12 weeks?
*
How confident are you about staying consistent right now?
*
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
What has gotten in the way of training in the past?
Health Screening
These are standard pre-exercise screening questions. Answering yes to one or more doesn't mean you can't train — it means I need to know before I program for you, and in some cases I'll ask you to get clearance from your doctor first.
Heart condition or only doctor-recommended physical activity?
*
Yes
No
Chest pain during physical activity?
*
Yes
No
Chest pain when not physically active in the past month?
*
Yes
No
Dizziness, balance loss, or loss of consciousness?
*
Yes
No
Bone or joint problem that could be worsened by a change in physical activity?
*
Yes
No
Has a doctor prescribed blood pressure or heart condition medication?
*
Yes
No
Any other reason you should not do physical activity?
*
Yes
No
You answered yes to at least one screening question. That's common and usually not a barrier — but before we begin training I'll need written clearance from your physician. I'll send you a clearance form to take to your appointment, and we can start planning in the meantime.
Have you already been cleared by a physician for exercise?
Yes, I have current clearance
No, not yet
I have an appointment scheduled
Please give any detail on the screening questions you answered yes to.
Medical & Injury History
Do you have any of these medical conditions?
*
None of these
High blood pressure
High cholesterol
Diabetes or prediabetes
Asthma or breathing condition
Thyroid condition
Arthritis
Osteoporosis or low bone density
Heart condition
Neurological condition
Autoimmune condition
Anxiety or depression
Other
Current medications or supplements
Surgeries or hospitalizations in the last 2 years
Pregnancy or postpartum status
Yes - pregnant
Yes - postpartum within 12 months
No
Prefer not to say
Do you have any current pain areas?
No current pain
Neck
Shoulder
Upper back
Lower back
Hip
Knee
Ankle or foot
Elbow
Wrist or hand
Other
Describe your current pain
Past injuries or surgeries
Movements or exercises to avoid, or that cause problems
Have you done physical therapy in the past 2 years?
Yes, currently
Yes, in the past
No
If yes, what was it for and did you complete it?
Mobility limitations you are aware of
Training Background
Current training experience
*
Please Select
Complete beginner, never trained
Beginner, less than 6 months
Some experience, trained on and off
Intermediate, trained consistently 1-3 years
Advanced, trained consistently 3+ years
Time training consistently in current routine
*
Please Select
Not currently training
Less than 1 month
1-3 months
3-6 months
6-12 months
Over a year
What does your current training look like? Include your typical week
*
Comfort with barbell lifts
*
Please Select
Never done them
Tried them but unsure of my form
Comfortable with some
Comfortable with all of them
Current or best lifts
Training styles you enjoy
Lifting heavy
Bodybuilding style training
Circuits and conditioning
Running
Rucking
Sports
Group settings
Training alone
Not sure yet
Training types you strongly dislike or want to avoid
Have you worked with a personal trainer before?
*
Yes
No
If yes, what worked well and what did not?
Your Weekly In-Person Session
Tier 2 includes one in-person session with me each week, plus your programming for the days you train on your own. Let's find a time that works.
Select all that could work
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred time of day
Early morning before 7am
Morning 7-11am
Midday 11am-2pm
Afternoon 2-5pm
Evening after 5pm
Flexible
Any day or time that absolutely does not work
Willingness to travel for the session
Under 10 minutes
10-20 minutes
20-30 minutes
Over 30 minutes
Scheduling constraints to plan around
Your Solo Training Days
How many additional solo training days per week can you commit to?
*
1
2
3
4
5
What is your typical solo session length?
*
Please Select
Under 30 minutes
30-45 minutes
45-60 minutes
60-90 minutes
Where will you usually train on your solo days?
*
Please Select
Commercial gym
Home gym
Base or unit gym
Apartment or hotel gym
Mix of places
What equipment is available on your solo training days?
*
Full commercial gym
Squat rack or power cage
Barbell and plates
Dumbbells
Kettlebells
Cable machine
Machines and selectorized equipment
Pull-up bar
Resistance bands
Cardio equipment
Limited or bodyweight only
Can you film your lifts on solo days and send them for form review?
*
Yes
No
I'd need help figuring that out
Lifestyle
Average sleep per night
*
Please Select
Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours
Sleep quality
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Daily stress level
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Job activity level
*
Please Select
Desk job, mostly sitting
Mixed sitting and standing
On my feet most of the day
Physically demanding labor
Approximate daily step count
*
Please Select
Under 4,000
4,000-7,000
7,000-10,000
10,000-15,000
Over 15,000
Not sure
Current nutrition description
*
Not something I pay attention to
I try but I'm inconsistent
Fairly dialed in
Very dialed in, I track
Tobacco/nicotine use
*
Yes
No
Occasionally
Typical weekly alcoholic drinks
*
Please Select
0
1-3
4-7
8-14
More than 14
Coaching & Communication
Preferred coaching style
*
Direct and demanding
Encouraging and supportive
Educational, explain the why
A mix depending on the day
Best way to reach you between sessions
*
Text
Email
Phone call
Whichever is easiest
Desired accountability level
*
Check in on me often, I need the push
Moderate, weekly is enough
Light touch, I'm self-motivated
Anything else we should know before building your program
How did you hear about Functionally Fitness?
*
Please Select
Referral from a friend or client
Google search
Google Business Profile
Facebook
Instagram
Partner business referral
Word of mouth at Fort Campbell
Other
Agreement
Consent
*
I agree that the information I have provided is true and complete to the best of my knowledge, and I understand that participation in fitness training involves inherent risks, including the risk of injury.
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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