New Client Intake Form for Mayfield Motivation Fitness LLC

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Contact Information* This field is required.
First Name
Last Name
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* This field is required.
Phone
Email
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Personal Information* This field is required.
Occupation
Birthdate ( We want to celebrate you!)
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* This field is required.
Gender
Weight
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Emergency Contact Information* This field is required.
First Name
Last Name
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* This field is required.
Phone
Relation
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1a. Do you have any current or past injuries?* This field is required.
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1b. Do you have any chronic conditions (e.g., diabetes, asthma, heart disease)?* This field is required.
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1c. Are you currently taking any medications?* This field is required.
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1d. Have you recently undergone surgery?* This field is required.
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1e. Have you been advised by a doctor to avoid certain activities?* This field is required.
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2a. Do you follow a specific diet or nutrition plan?* This field is required.
Yes
No
Currently no, but I have tried a specific diet or nutrition plan in the past.
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2b. How many meals do you typically eat per day?* This field is required.
3 or more
2 at least but no more than 3
1 at least but no more than 2
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2c. Do you take any supplements?* This field is required.
Yes
No
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2d. Are there any foods you avoid?* This field is required.
Yes
No
Due to allergy restrictions
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2e. How many hours of sleep do you get on average per night?* This field is required.
6-8 hours
4-6 hours
4 or fewer hours
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What is your biggest challenge when it comes to nutrition, if any?
When submitting an explanation please reference the related question (i.e "1a: then proceed with explanation)
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3a. How many hours of sleep do you get on average per night?* This field is required.
8 or more hours
5-7 hours
4 or fewer hours
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3b. On a scale of 1-10, how would you rate your current stress level?* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
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3c. How would you describe your current activity level?* This field is required.
Very Active
Moderately Active
Lightly Active
Inactive
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3d. How often do you currently exercise?* This field is required.
5-7 days per week
2-4 days per week
1 or no days per week
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3e. What are your hobbies and interests?* This field is required.
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4a. What are your primary fitness goals?* This field is required.
Weight Loss
Muscle Gain
Improve Flexibility
Increase Endurance
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4b. Do you have any specific fitness milestones you want to achieve? (e.g., run a marathon, lift a certain weight)
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4c. If yes, What is your timeline for achieving these goals?
1 year
6 Months
90 Days
60 days or fewer
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4d. Are there any specific areas of your body you would like to focus on?
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4e. Do you have any past experiences with fitness programs or trainers? If yes, what worked and what didn’t? Please include approx. date of last session
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5a. How many days per week are you available for training?* This field is required.
3 or more
1-2
Unsure, let's see how this goes
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5b. What times of day and days of the week do you prefer to train? Check all that apply.* This field is required.
Morning
Afternoons
Evenings
Weekdays
Saturday
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5c. Do you prefer in-person (at gym) or will you be training at home (virtual)?* This field is required.
I will be training at home
I would like to alternate between at-home and at the gym
I am will be training at the gym
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5d. What equipment do you have access to at home?
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6a. What motivates you to stay fit and healthy?
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6b. Which best describes how you prefer to receive feedback? (e.g., direct, encouraging, structured)
Direct
Encouraging
Structured
"Tough Love"
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6c. Do you prefer to train alone or with others?
Solo
Group
Open to both
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6d. What type of training do you enjoy the most?
Strength Training
Cardio
HIIT
Yoga
Other
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6e. Are there any exercises you dislike or want to avoid? If yes, please specify.
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Explanations
When submitting an explanation please reference the related question (i.e "1a: then proceed with explanation)
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Is there anything else you'd like your trainer to know?Do you have any specific concerns or questions about starting a fitness program?
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