New Client Intake Form
Please fill out the following form to the best of your ability to help me create a customized plan for you. I look forward to working with you!
Email *
Name *
Age *
Current Weight *
Height *
What is your mailing address? *
Short Term Goals *
Long Term Goals *
What do you do for a living? *
Are you taking any medications? *
Do you have any injuries? *
Do you have any food allergies or sensitivites? *
What foods do you hate? *
What foods do you love? *
What does your current diet look like? Sample day. *
How many alcoholic beverages do you consume per day?
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Do you struggle with any of the following? Check all that apply.
Have you ever had an eating disorder?
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How many meals/snacks per day is ideal for you? *
How much water do you drink per day? *
List any nutritional supplements you are taking *
What is your current workout routine? *
What time of day do you usually workout? If you're not currently exercising, what time would be ideal with your schedule? *
How would you describe your stress levels at work? *
How would you describe your stress levels at home? *
Are you currently pregnant? *
Are you currently postpartum, lactating, or trying to conceive? *
What is your current cardio routine? *
Do you prefer a home or gym based workout program? *
If home based, what equipment, if any, do you have available?
Is there anything else you think I should know about your health or mindset?
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