CATE SANDERS HEALTH INTAKE FORM

Client Intake Questionnaire

All of your information will remain confidential between you and your Fitness & Health Coach.
PERSONAL INFORMATION
Name*

First NameLast Name
Email*
example@example.com
How often do you check email?*
example@example.com
Home Phone
Format: (000) 000-0000.
Mobile Phone*
Format: (000) 000-0000.
Age*
Height*
Birthdate*

MonthDayYear
Date
Current weight*
Weight six months ago*
One year ago*
Would you like your weight to be different?

NoYesNot sure
If yes, what would you like your weight to be?
SOCIAL INFORMATION
Relationship status*
Where do you currently live?*
Children*
Pets*
Occupation*
Hours of work per week*
What does your general activity level look like throughout the day?*
HEALTH INFORMATION
Please list your main health & fitness concerns*
Other concerns and/or goals?*
At what point in your life did you feel best?*
Any serious illnesses/hospitalizations/injuries?*
How is/was the health of your mother?*
How is/was the health of your father?*
How is your sleep?*
How many hours?*
Do you wake up at night? If yes, why?*
Any pain, stiffness, or swelling?*
Constipation/Diarrhea/Gas?*
Allergies or sensitivities? Please explain*
Does Women's Health apply to you? Checking "No" will remove the Women's Health questions.*

YesNo
WOMEN'S HEALTH
Are your periods regular?
How frequent?
Reached or approaching menopause?
Painful or symptomatic? Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain
MEDICAL INFORMATION
Do you take any supplements or medications? Please list*
Any healers, helpers, or therapies with which you are involved? Please list*
What role do sports and exercise play in your life?*
What foods did you eat often as a child? *
Breakfast, Lunch, Dinner, Snacks, Liquids
What is your food intake like currently?*
Breakfast, Lunch, Dinner, Snacks, Liquids
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?*
Do you cook?*
What percentage of your food is cooked at home ? If not 100% where do you get the rest from?*
Do you crave sugar, coffee, cigarettes, or have any major addictions?*
I feel the most important thing I should do to improve my health is...*
EXERCISE
Do you exercise regularly?*

YesNo
How often during the week do you exercise?*
What types of exercise do you do?*
Do you have any specific fitness goals? If so, please explain*
ADDITIONAL COMMENTS
Anything else you would like to share?
Should be Empty:

Client Intake Questionnaire

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

WOMEN'S HEALTH

MEDICAL INFORMATION

EXERCISE

ADDITIONAL COMMENTS