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Client Intake Form
Please answer the following questions so we can better help you reach your goals!
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Name
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First and last name
Your answer
Email
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Your answer
Phone number
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Your answer
Which program are you interested in?
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Nutrition Coaching
Personal Training
Both!
Are you currently seeing or in the past have you seen a medical provider, registered dietician, or any other professional regarding your nutrition? If so, please explain in detail.
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Your answer
What does your current fitness routine consist of? (If anything). Be as detailed as possible.
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Your answer
What does your daily diet consist of? Be as detailed as possible.
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Your answer
How do you feel on a daily basis, energy, strength, performance, etc?
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Your answer
Rate your current stress level from 1-5. 1 meaning "rarely stressed", 5 meaning "all the time":
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1
2
3
4
5
Required
Are there any physical limitations or injuries that could interfere with your ability to exercise? Include any and all, no matter how insignificant.
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Your answer
Are you currently taking any medications or supplements that could interfere with your ability to exercise or performance in the gym? Include any and all, no matter how insignificant.
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Your answer
What are your overall longterm goals that you would like to work towards? Include any and all.
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Your answer
What would you like to accomplish in the next 3 months, 6 months, and 1 year? Include any and all.
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Your answer
Out of all of your goals, which ones feel the most important? Choose the top 3.
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Your answer
What, if any, are possible barriers to reaching your goals?
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Your answer
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? Include any and all.
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Your answer
Which of those worked best for you and why? (Even just a little bit, and even if you might not be doing them right now.)
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Your answer
Which of those didn't work for you and why not?
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Your answer
On average, how many hours of sleep do you get a night?
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Your answer
On a scale of 1-5, how READY are you to change your behaviors and habits? (1 meaning not ready, 5 meaning ready for action!)
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1
2
3
4
5
Required
How WILLING are you to change your behaviors and habits? (1 meaning not willing, 5 meaning completely willing)
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1
2
3
4
5
Required
How ABLE are you to change your behaviors and habits? (1 meaning not able, 5 meaning completely able)
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1
2
3
4
5
Required
What are your expectations from your coach?
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Your answer
How would you like your coach to hold you accountable?
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Your answer
- If you are a Personal Training client,
please list out the days and times you would usually like to schedule your 1 hour sessions so we can pair you up with a Trainer with similar availability
- If you are not a personal training client, type "NA".
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Your answer
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