Intake Form Name * First Name Last Name Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday * DD/MM/YYYY Gender * Female Male What are your short term and long term goals? * If you look 6 months down the road what improvements would you like to see then? Have you had a fitness coach before? * If so, how was your experience? What do you want out of a coach? * What are your expectations of me? What areas do you need support with? Current Health Status * Do you have any medical conditions? Concerns? Issues? Have you been hospitalized in the past 2 years? Any past injuries? If so what? Do you consume alcohol? * If so, how often? And how much? Do you smoke cigarettes? * If so, how often? How much? Do you do any other drugs? * If so, what and how often? Are you pregnant or breastfeeding? * Medications and Supplements? * Fitness & Activity History * What is your fitness/activity lifestyle history and as of now? Past and current activity level. How many days can you commit to working out and for how long? * Where will you be performing your workouts? * In the gym, at home, apartment gym? What is your daily nutrition and eating habits? * Describe an average day in the life with your food. If you can, include measurements. Any allergies/sensitivities etc? * Do you know about Macro Counting? * Yes Kind of No Describe Life, Work and/or School * What does a day in the life look for you during the week? Your work schedule, school, weekends? This allows me to help create a plan that fits into your routine as best as we can. Reoccurring Life Stressors? * Do you have any life stressors that routinely pop up? (This can be exams at school, overtime at work, last minute surprises with loved ones.) Tell me more about yourself! Do you have any passions outside of fitness? Goals? Dreams? Hobbies? * Emergency Contact Information * Please add emergency contact information. (Name, Email and/or Phone and Relation to you). Thank you! I will reach out if I have anymore questions in order to begin creating your plan.
