The Factory Nutrition Coaching Intake Form

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In order for me to be the best resource for you possible, please fill out the information below.

Please recognize the fact that it is your responsibility to work directly with your physician
before, during, and after seeking fitness consultation. As such, any information provided
is not to be followed without the prior approval of your physician. If you choose to use this
information without the prior consent of your physician, you are agreeing to accept full
responsibility for your decision.

Email *

Name: *

Age: *

Weight: *

Height: *

Body Fat Percentage: (if known, please include date for your measurement if applicable)

Goal: *

Fat Loss (Recommended for Males Above 20% Body Fat and Females Above 25% Body Fat)

Muscle Gain (Recommended for Males Below 12-15% Body Fat and Females Below 17-20% Body Fat)

Performance Focus/Body Composition Maintenance

Health

Other:

How many times per week do you train/exercise?: (number of sessions per week) *

What is the typical duration of your training/exercise?: (number of minutes per session ON AVERAGE) *

What do you do for a living: *

What is the activity level at your job?: *

None (mostly seated work)

Moderate (light activity such as walking)

High (heavy labor, very active)

Do You Have a Specific Goal? Please Explain:

Readiness for Change/Motivation Level: *

Not Ready to Commit, Feeling a Little Apprehensive About Changing

Extremely Driven, Will Do Everything Necessary to Succeed

If less than a 8/10, why? Why is this goal important to you?

How Will You Know You're Making Progress Toward Your Goal?: *

Do You Have a Specific Timeline for Achieving This Goal? Please Explain:

What Are Your Expectations From Me As Your Coach? *

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