SELF-LOVE AND FITNESS INTAKE FORM
All client information is held under the strictest confidence.
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First and last name *
E-mail address *
Phone number *
Country *
Province or State *
Age *
Weight *
Height *
Approximate body fat percentage (no need to measure if unsure, if not sure, "unknown" is an okay response). *
As a client of the program, how do you prefer to communicate in between Zoom  calls? *
What file storage system do you prefer to deliver your program to you? *
Nutrition and fitness goals *
Required
Preferred method of grocery shopping? *
Favourite take-out restaurant and overall comfort-food style meals? (I am asking so that we can look at healthified versions of your favourite comfort foods, this may not be needed, but depending on your goals it may be helpful). *
Amount of weights you can lift in pounds - either using one hand with dumbbells or both hands with a kettlebell? Total weight you can lift off the ground and total weight you can lift overhead? *
Number of Litres of water per day? *
Please list any medication you are currently on? (To ensure no interactions with any supplementation we may recommend). *
Current supplements? *
Required
Current level of fitness and fitness routine? (Even if your chosen consultation may be for nutrition only - your exercise patterns are relevant). *
How often do you train and would you like to train more often? *
Please check off each day that you would like to train and the days you leave blank will be rest days. The rest days and training days can be flexible; however, this is a great as a general idea. *
Required
Please describe and list any fitness equipment you currently own. If you own weights, is it barbells, kettlebells, or dumbbells, and how many pounds? Do you have a flat or incline bench? Resistance bands? Etc. *
Journaling prompt: What does your relationship with food look like, what did you get fed growing up, and what does food do for you? Does it serve any emotional needs? Is it something that you gravitate to for comfort? Do your eating habits change frequently? Is food viewed as a source of fuel, entertainment, both? Feel free to answer in bullet-form. *
Please list your food allergies (dairy, seafood, for example) and any foods that you cannot tolerate or have sensitivities toward, in addition to the types of foods you dislike (so that we do not include those in your recommendations). *
Do you have a history of respiratory or other serious illnesses that would require you to get clearance from a physician before starting an exercise program? *
Do you have a history of kidney issues? *
Are you currently or have you ever been diagnosed with any type of diabetes? *
Do you have a history or current issues with eating disorders? *
Do you have any physiotherapy or bone-related issues? *
By participating in this program, you have read the following disclaimer and agree: This program and its content is not intended to diagnose or treat any diseases. Always consult with your primary care physician or licensed healthcare provider for all diagnosis and treatment of any diseases or conditions, for medications or medical advice as well as before changing your health care regimen. You release Self-Love and Fitness of all liabilities from taking the advice given. *
Willingness to leave a public review if satisfied with the program should you choose to enroll? *
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