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Comprehensive Initial Intake Form
Health and Wellness Profile
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Prefer not to say
Other:
How do you prefer to be contacted?
*
Which method of contact do you prefer?
Email
Phone
Text
Other:
Phone Number
*
Your answer
Current Body Weight (in pounds)
Your answer
Current body fat % (if known)
0-5%
6-10%
11-15%
16-20%
21-30%
31-40%
41-50%
50% or over
Not sure
Clear selection
Method used to determine body fat
Bio-electrical Impedance (BIA)
Hydrostatic Water
DEXA / Bod Pod
Caliper Method - 3 site
Caliper Method - 7 site
Other:
Clear selection
Tell us more about yourself.
Simple enough, Who are you? (hint it's a loaded question) By learning more about your lifestyle and your habits, we can take better care of you and determine which coaching service is a good fit for your goals and individual needs. No need to get into a novel here just 4 or 5 sentences to describe where you're at in your life will help.
Your answer
What do you want to achieve working together?
In general, what are your goals? Check all that apply.
Lose weight/fat
Gain weight
Maintain weight
Add muscle
Improve physical fitness
Get stronger
Improve athletic performance
Physique competition/modeling
Get control of eating habits
Have more daily energy and vitality
Reduce stress
Improve mental focus
Improve happiness / sense of fullfillment
Other:
Right now, what things are holding you back from improving these things you've listed above?
Your answer
Please list all of your concerns about your health, eating habits, fitness, and/or body.
Your answer
Out of all of the above concerns, which ones (top 3) feel most important/urgent?
Your answer
Why do they feel most urgent to you?
Your answer
What do you expect from working together?
What do you expect from me as your coach?
Your answer
What do you think we expect from you?
What are you prepared to do to work towards your goals?
Your answer
What have you already tried to change?
Have you tried anything in the past to change your habits, your health, your eating, and/or your body? If so, what?
Your answer
Which of those things worked well for you? (Even if you might not be doing it right now.)
Your answer
Which of those things didn't work well for you? Or maybe it worked for a short while but stopped working?
Your answer
Right now, how would you rank your overall eating/nutrition habits?
1 (Horrible)
2
3 (okay)
4
5 (Awesome!!!)
Why did you rate yourself that?
Your answer
Are you regularly active in sports and/or exercise?
Yes
No
Clear selection
If so, approximately how many hours per week?
0-4
5-9
10-14
15-19
20 or more
Clear selection
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