Time for Health - Client Intake Form
Event Timing: Intake Form for 3, 6 & 12 Month One on One Coaching
Time for Health - Lexi Wright
Contact me at (403) 862-5600 or timeforhealth19@gmail.com

Price packages for 3 months, 6 months and 12 months for One on One Nutrition coaching.  Request more details from Lexi on what is included and pricing.  If you require training programs please reach out to Lexi or answer in the questionnaire below.

Before you fill out make sure you have the below items ready!

1. BEFORE PHOTOS -All photos for the intake must be emailed at the time of your intake.
 - Please take photos with Sports bra or tank top and either shorts or tights (women). No shirt or muscle shirt (men) and shorts. Must have front, back and side photos for submission. Email to timeforhealth19@gmail.com

2. CALORIE LOG - showing 4 days with foods from MyFitness Pal or your tracking app. I will send you a  link to Everfit and you can link your MyFitnessPal in the App.  If you have Fat Secret please add me as a professional with the lexiwright19@gmail.com or lexiwright19

Please note all information and photos provided to Time for Health (Lexi Wright) is confidential and will not be shared without your consent.  

Once your form has been submitted you will receive a welcome package with information on the next steps to get started in your program.
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Email *
Email Address *
Referral - If someone referred you please let me know their name.  If not put NA *
First Name *
Last Name *
Phone Number *
City *
Address *
Postal Code *
Province/State
How do you prefer I contact you?
Clear selection
How Will you be paying? *
Required
Credit Card Number (put security & expiry below)
Credit Card Expiry Date
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Credit Card Security #
Sex *
Age *
Birthdate *
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Weight (in lbs) *
Height in Feet & Inches *
Measurements - Waist in inches (Measure right across your belly button). *
Measurements - Hips in inches ( Place tape measure around the “last thing to hit the door on the way out"). *
Measurements - Chest/Bust in inches (Measure around the chest – right across the nipple line) *
Measurements Arms in inches (Measure around the biggest part of the upper arm). Do both arms *
Measurements Thighs in inches (Measure around the biggest part of each thigh). Do both thighs *
Measurements around neck - inches *
Are you pregnant or nursing? *
Required
1 Week of Calories Tracked. I have sent you a Everfit invite please link your My Fitness Pal if you are on Fat secret please invite me as a professional with timeforhealth19@gmail.com.  Indicate below which app you are using. *
Required
If using MyFitnesspal, what is your myfitnessPalID (make sure you invite me to be a friend & open your diary settings to public) *
Before Photos (please take front, back and side photos for submission) *
What are your Goals?  Choose all that apply *
Required
Of all the Goals you chose above what is your 1st and 2nd priority in that order *
Please list all of you concerns about your eating habits, fitness and or body image. *
Out of all of the above concerns which do you feel is the highest priority?
Have you ever felt you had or been diagnosed with an eating disorder?  If so what type? *
Have you tried to do anything in the past to change your habits, your health, your eating and or your body? If so what and elaborate on what worked well and what didn't.  This can be fitness and or nutrition related. *
Would you say you currently eat more calories on the weekend days then during the week? *
What do you feel your limiting factors have been when it comes to achieving your goals.  List all that you can think of here.  (eg: Time, Knowledge, responsibilities, access to a gym etc.)
Have you made any changes recently to your diet and or fitness and if so when? *
Do you currently work out? If so how many times a week do you work out and how many hours are your sessions.  What type of activity/workouts?  Please include amount of strength, cardio, Crossfit or exercise type. Please detail out. *
What time of day do you work out? If you work out in morning please note if you work out fasted. *
Do you require a workout package? If so how many days a week *
How many hours a week do you do other types of physical activity.  (walking, gardening etc please include here if you have a physical job) *
Diet methods you have tried in the past *
Required
Tell me about your experiences with past diets.  Did they work for you?  What were your overall experiences both positive and negative. If you chose other in above question please explain diet here. *
Do you currently skip meals or late night snack? IF so what kind of snacks and how often are you skipping meals. *
Dietary Preferences (do you have any) *
Do you have any food preferences (foods you prefer to eat or NOT eat). If not please answer no otherwise elaborate.  If you answered other above please include what Other entails. *
Do you have any Food allergies or intolerences?  If so please list here.
How many drinks (alcohol) do you have each week? *
Who lives with you?  Choose all that apply. *
Required
Who does most of the cooking in your house? *
Do you have any digestive issues?  (eg: are your bowel movements regular). If you do please elaborate on # bowel movements a day. *
Do you currently experience in inflammation issues?  If so when do you notice this inflammation and where does it occur in your body? *
What does your typical day look like? Include from time you get up until time you go to bed.  Times, workouts, activities, meal times, snack times. Very important to be as much detail as possible. *
Are you currently employed? *
What is your Occupation *
If you answered yes above. Do you work part time or full time?
Clear selection
Do you work from home currently?
Clear selection
Given the current demands of your life, what is your typical stress level on an average day?  1 being no stress 10 being extreme *
How do you normally deal with your stress? *
Do you have any preexisting medical conditions or health concerns?  Please list. Eg: Diabetic or Autoimmune, Thyroid) *
Do you current have a menstral cycle (if female)?
Clear selection
Are you currently taking any prescribed medication? (please include all - eg: Birth Control, Blood pressure , thyroid etc).  If not please answer NO.
Are you currently taking any other supplements? (eg: Omegas, Vitamin C, Protein powders, Creatine, Magnesium etc).  If not please answer no. *
How many hours a night do you sleep? *
What is your sleep quality like? (# of times up or awake, restful or not?) *
Are you currently suffering from any injuries and or pain I should be aware of?  Also have you recently had any surgeries. If so please describe.
Is there any other relevant information I should know in regards to you, your current state of health, lifestyle or relationships.
What is your level of commitment on a scale of 1 to 10 in regards to meeting your goals?  1 low to 10 is high *
What are your expectations from me as your coach? *
What do you think held you back from achieving your goals in the past?
Are you ready to make a commitment for this to be the last thing you start?
Clear selection
Disclaimer: Each individual’s health, fitness, and nutrition success depends on his or her background, dedication, desire, and motivation. As with any health-related program or service, your results may vary, and will be based on many variables, including but not limited to, your individual capacity, life experience, unique health and genetic profile, starting point, expertise, and level of commitment.  The photos will be the property of Time for Health and will be used only with the participants consent. *
Required
Signature (Type in Name) *
Date Signed *
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