New Client Intake Information

New Client Intake Information

All information submitted will remain confidential and not sold or shared with any person or third party companies.
*Please read carefully and fill out all sections thoroughly*
Name*

First NameLast Name
Email*
Phone Number*

Area CodePhone Number
Where are you located*
Age*
MaleFemale
Fasted Scale Weight*
Height*
Resting/Waking Heart Rate*
Blood Pressure*
Client Questionnaire
Summarize your current occupation*
How often do you exercise per week?*
Gym,sports,etc
Example of Exercise*
If following a program, please describe workout split, exercises, reps, rests and sets
What are your immediate goals?*
How many meals do you eat per day?*
Provide a detailed diet history*
Are you a snacker?*
Examples of favored foods?*
Please be very thorough
Examples of least favored foods?*
Please be very thorough
Any food allergies?*
Provide brief description
On average, how many hours of sleep per night?*
How would you rate your quality of sleep on a scale of 1-10?Explain your rating*
How would you rate your stress level on a scale of 1-10?Explain your rating*
What are some steps you take to manage your stress?*
Do you suffer from Anxiety or Depression?*
Do you experience any bloating, abdominal pain, etc?*
Do you consume alcohol or drugs?*
Provide frequency
Have you ever or are currently using anabolic steroids or any form of performance enhancing drug?*
Provide brief description
Any additional information?*
Provide a detailed list of supplements you’re currently taking*
Provide brands and dosages
*If you have any recent blood work done, please provide

Please email to:

curtis@lifestylempowerment.ca

(Click & hold email link if using mobile device)
Medical History
Have you experienced any past injuries or illness?*
Do these past injuries or illnesses prevent you from performing physical activity?*
Chest PainDizzinessNauseaLoss of consciousnessBone or joint problems
Have you experienced any of these symptoms listed above away from physical activity?*
Are you currently on any medications?*
Provide brief description
Any other conditions preventing you from performing physical activity?*
Are you currently or have been on Birth Control?
If so, which one are you using? If removed, when did you remove Birth Control?
Body Composition Photo's

I understand that these photos can make you uncomfortable, but they are one of the most important parts of the process. Please upload photos below, such as wearing a sports bra and underwear for women, and underwear for men, exposing the full abdomen. Additionally, capturing the back of your knees will help better assess what is going on.

Make sure to have light facing you, avoid being in the darker areas, using a tripod with a self timer on your camera is usually the most efficient.
Please Upload Front Body Composition Photo Here*

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Please Upload Side Body Composition Photo Here*

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Please Upload Back Body Composition Photo Here*

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Should be Empty:

New Client Intake Information

Client Questionnaire

Medical History