Lifestyle Coaching Intake Form

Lifestyle Coaching Intake Form

Please answer the questions below with as much detail as possible. This will help me to really know and understand you and your goals so I can create the best plans for you!
INTRODUCTION
Name*

First NameLast Name
Age*
DOB*
Height*
Weight (morning weight, after using the restroom & prior to eating or drinking)*
What do you do for work & what does a typical day look like for you? *
How many steps per day do you average? (If you do not have something like a Fitbit or Apple watch that tracks steps, your smartphone should have a health app that tracks them.)*
Which Lifestyle Coaching plan do you plan to purchase?*
DIET & NUTRITION

Please be very specific here. My goal is to create a plan that works for YOU! We want it to support your goals while being sustainable & including your tastes & preferences.
Allergies &/or Intolerances: *
Likes & Favorite Foods (Please include ALL of your faves – even if they are ones you might be trying to decrease intake of or that you do not consider “healthy”. There truly are no “bad” foods. And it helps me to have a thorough understanding of the foods you enjoy.)*
Foods you dislike.*
Tell me about your current diet. (Please outline what a typical day might look like for you. Include quantities. For instance, instead of saying eggs & toast, it helps me understand your caloric & macronutrient intake if you tell me 3 eggs & 2 slices of toast & butter.)*
Training History
What physical activities or types of exercise have you done in the past (include any history of sports or exercise classes)?*
Please tell me about your most recent activity levels. What has the last month or 2 been like for you in terms of activity level?*
If you are currently weightlifting, what is your current training split? How many days per week?*
Are you currently doing any form of cardio? If so, what type and approximately how often for how long?*
Access to Exercise Equipment – Do you currently attend a gym? Do you have exercise equipment at home? If so, what types of equipment do you have?*
If you attend a gym, how many years have you been going to the gym?*
What are your favorite activities & exercise modalities?*
What time of day do you prefer to train? Please be as clear as possible so I can tailor your diet around training. Do not just say “morning” or “late afternoon”.*
What time of day do you typically wake up?*
What time of day do you typically go to bed?*
HEALTH
Do you have any medical diagnoses, health issues or concerns that you feel would be helpful to share so I can best serve you?*
Do you take any prescription medications or health supplements?*
YOUR GOALS
What do you hope to achieve in the short term with me?*
What is your long term goal?*
Once form is submitted, please email current pictures (front, back, side and side).
DISCLAIMER
I,name*, certify and acknowledge: That Evolve Personal Performance and associates (in association with Evolve Personal Performance, LLC), are independent personal trainers and nutrition advisors, and have advised me prior to my commencement of participation in cardiovascular resistance training programs and diet that such participation could result in physical injury.
That I, name*, freely and knowingly assume the risk in such programs, and I hereby waive any right, claim, or cause of action against Evolve Personal Performance and associates and release them and/or associates from any liability for any injury, illness, cost, damage expense or claim, which I or anyone on my behalf might incur as a direct or indirect result of my participation in this cardiovascular, resistance-training program and diet.
That I,name*, fully understand that Evolve Personal Performance and associates have the right to terminate my plan based on declining health, both physical and mental.
That I,name*, fully understand the qualification that Evolve Personal Performance and associates hold, and understand that the advise given is hypothetical and not given from a medical or nutritional professions.
That I,name*, freely and knowingly accept that there is NO REFUND once initial plan is received.
That I,name*, have read this Liability Waiver form, understand and agree with each of the aforementioned points, and have received a copy of this release from on this date. A signature below and payment will be taken as signature and agreement of this liability waiver from and also confirms that the information I have provided to Evolve Personal Performance and associates is correct and true.
Signature*
Date*
Contact & Communication With Us

Users contacting us through this website do so at their own discretion and provide any such personal details requested at their own risk. Your personal information is kept private and stored securely until a time it is no longer required or has no use. Where we have clearly stated and made you aware of the fact, and where you have given your express permission, we may use your details to send you products/services information through a mailing list system. This is done in accordance with the regulations name in the policy above.
Social Media Policy & Usage
We adopt a Social Media Policy to ensure our business and our staff conduct themselves accordingly online. While we may have official profiles on social media platforms, users are advised to verify authenticity of such profiles before engaging with, or sharing information with such profiles. I, name*, release any pictures to Evolve Personal Performance and associates to use for social media/marketing purposes. We will never ask for user passwords or personal details on social media platforms. Users are advised to conduct themselves appropriately when engaging with us on social media.

There may be instances where our website features social sharing buttons, which help share web content directly from web pages to the respective social media platforms. you use social sharing buttons at your own discretion and accept that doing so may publish content to your social media profile feed or page.
By making payment you agree that you have read and accept the terms and conditions as detailed her in our Privacy Policy.
My Products
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1 Month Lifestyle CoachingYour payment will automatically renew after 1 month. It is the client's responsibility to cancel the payment if services will be canceled. No refunds given as the client will still have full access to all coaching information once renewed.
$150.00 for each month



3 Month Lifestyle Coaching Payment will be withdrawn every month at the same time. The 3 month subscription will automatically renew after 3 months. It is the client's responsibility to cancel the payment if services will be canceled. No refunds given as the client will still have full access to all coaching information for a 3 month period once renewed.
$142.66 for each month



6 Month Lifestyle CoachingPayment will be withdrawn every month at the same time. The 6 month subscription will automatically renew after 6 months. It is the client's responsibility to cancel the payment if services will be canceled. No refunds given as the client will still have full access to all coaching information for a 6 month period once renewed.
$135.00 for each month



12 Month Lifestyle CoachingPayment will be withdrawn every month at the same time. The 12 month subscription will automatically renew after 12 months. It is the client's responsibility to cancel the payment if services will be canceled. No refunds given as the client will still have full access to all coaching information for a 12 month period once renewed.
$127.50 for each month



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$0.00
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Lifestyle Coaching Intake Form

INTRODUCTION

DIET & NUTRITION

Training History

HEALTH

YOUR GOALS

Once form is submitted, please email current pictures (front, back, side and side).

DISCLAIMER

Contact & Communication With Us

Social Media Policy & Usage