Client Details:
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
What are your short term goals?
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What are your long term goals?
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How do you want to feel when you finish your plan?
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How do you want to look when you finish your plan?
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Slim
Toned
Muscular
Curvy
Proportionate
What are the areas that you would like to see the most progress in?
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Do you have any history in competing. If so, when?
*
Have you played sports in the past or been apart of any exercise regimens? If so, please explain.
*
Do you have any food allergies?
*
Do you have any current or past illnesses, deficiencies, or diagnosis that I should know about?
*
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Height
*
Current Weight
*
Age
*
Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Current Body Fat Percentage, if known
What is your occupation?
*
What are the hours like?
*
Do you have access to a microwave and fridge?
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Both
Neither
Just a microwave
Just a fridge
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List out your favorite foods
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List out the foods you will not eat:
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What does a typical day of nutrition look like for you?
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How much water do you typically drink per day?
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Do you know your current macro intake?
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Do you currently make time to meal prep?
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Yes
No
Occasionally
How many times per week do eat out?
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Have you ever been on a restricted diet?
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Do you currently use MyFitnessPal or a tracker of some sort?
*
What is your day to day activity level?
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Sedentary - sitting at a desk
Moderately Active - Standing/Walking around
Active - Strenuous activity
Do you currently exercise? If so, please try to explain your current regimen.
*
Do you have access to a full gym? If not, please explain what is available to you.
*
What is your favorite body part to train? and least favorite to train?
*
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What would you say the hardest part to adhering to a nutrition plan is for you?
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What would you say the hardest part to adhering to a training plan is for you?
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What do you think your strengths and weakness are?
*
Do you currently have time constraints?
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Yes
No
Are you willing to send me progress photos to track your progress throughout the plan? (This will be in a two piece bathing suit, in natural light, have your body head to toe in it with front, back, and side)
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Yes
No
Acknowledge: I, Alyssa Blessing, will not sell or giveaway your information. It will remain confidential. I will also keep your photos private and only share them with your permission for a testimonial of your transformation.
*
I read and understand this statement
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Contract for Commitment
Thank you for completing the intake form! Are you ready to reach your goals? To be okay with change? To form new habits? To turn down temptations? This is a huge step that you are taking and ill be the first to say that I am proud of you! This is a lifestyle change, you may be faced with people who wont get what you are doing and might not give their full support. That is what I am here for, I will fully support you along the way. I want you to succeed! The nutrition plans require a three month minimum to allow time to fully work with your body to set you up for success. There is no minimum with the training or life coaching plans. If you are ready, type your name below and lets begin.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
After I receive the intake form and the pictures, I will begin on your nutrition &/ fitness plan. Please allow me up to 5 days after the above date to complete the plan. If you have any further questions or concerns, please use the space below:
Submit
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