Client Intake Form
Client Name
*
First Name
Last Name
Gender
*
Male
Female
Birth Date
*
-
Month
-
Day
Year
Date
Age
*
Weight
*
lb
Height
*
Feet/Inches
Phone Number
Format: (000) 000-0000.
Preferred method of contact
*
Email
Text/SMS/IMessage
Messanger
Other
Medical/Health Information
State past, previous or present
Please state if you have current/previous health diseases/issues.
*
Be as specific as possible*
Please state if you have current/ past injuries and or areas of pain.
*
Be as specific as possible and include time frame*
Please state whether you take any medication.
*
Be as specific as possible*
Do you have any allergies/allergens?
*
Lifestyle Information
What is your activity level at your job?
*
None (mostly seated)
Moderate (Light walking/moving)
High (Very active, heavy labor)
How is your work schedule? (Work days, afternoons or nights)
*
Be as specific as possible*
How stressful is your job?
*
Little to no stress
0
1
2
3
4
Very Stressful
5
0 is Little to no stress, 5 is Very Stressful
How often do you travel?
*
A couple times per year
A couple times per months
Weekly
Rarely
Health & Lifestyle
*
Rows
Yes
No
Do you smoke?
Have you had any surgery since one year?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Have you done sports professionally before?
Do you feel pain while doing sports/exercise?
Are you currently following a diet or nutrition plan?
*
Yes
No
If yes, please explain in detail.
Do you currently take any dietary supplements? (protein powder, creatine, weight loss). Enter none if none.
*
How do you feel about your current eating/nutritional habits?
*
Liberal, I don't monitor what I eat, pretty much eat what I feel.
0
1
2
3
4
Very specific and conscious of what I eat. (fruits/veggies/ whole foods)
5
0 is Liberal, I don't monitor what I eat, pretty much eat what I feel., 5 is Very specific and conscious of what I eat. (fruits/veggies/ whole foods)
Goal Setting
To better understand what you want to achieve out of training.
What are your goals for training? (select all that apply)
*
Build muscle
Lose body fat/weight loss
Muscular strength and power
Increase flexibility
Cardiovascular endurance
Sports performance
Improve posture
Overall health
Reduce stress
Confidence/self-esteem
Other
If your goals aren't listed, please state them below
List your top 3 goals that you want to accomplish? (list in order of importance)
*
Explain why these goals are the most important to you
*
What are some pain points that you feel hinder your nutritional and fitness progress?
*
Time
Money
Lack of motivation
Stagnant results (plateau)
Self conscious
Figuring out where/how to start
Other
How often can you commit to exercise per week?
*
Please select the best days you can exercise.
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Exercise History
Do you or have you participated in competitive sports?
*
Yes
No
If yes, which sport and how often?
Have you trained at a commercial gym before with both free weight (dumbbells/barbell) and machines?
*
Yes
No
Have you trained with a personal trainer before?
*
Yes
No
If yes, was your experience negative or positive? Explain.
In your words, what do you expect of me as your coach?
*
Overall Readiness and Mentality
How ready are you mentally to make the changes necessary to reach your goals?
*
I am not ready to make any changes.
0
1
2
3
4
I am excited and ready to make any lifestyle changes to reach my goals!
5
0 is I am not ready to make any changes., 5 is I am excited and ready to make any lifestyle changes to reach my goals!
How motivated are you to do what it takes to achieve your goals?
*
I am not motivated to change my lifestyle.
0
1
2
3
4
I am excited and ready to make any lifestyle changes to reach my goals!
5
0 is I am not motivated to change my lifestyle., 5 is I am excited and ready to make any lifestyle changes to reach my goals!
What motivates you?
*
Following a program
Having a strong motivator to push you to train
Trying new things
Being held accountable
Pushing past comfort to achieve your goals
Seeing actual results
Being informed about your program and how it will aid in achieving goals
Other
When are you willing to start your training program?
-
Month
-
Day
Year
Date
Submit
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