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Pillars of Health - New Client Intake Form
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Email
*
Your email
Name
Your answer
How did you hear about us?
Your answer
What is your preferred communication method?
Email
Text
Other
Clear selection
If you answered "Text" please provide your phone number. If you answered "Other" please specify
Your answer
What is your age?
Your answer
What is your occupation?
Your answer
What are your pronouns? Name you prefer to go by?
Your answer
Have you worked with a trainer before?
Yes
No
Clear selection
What did you ENJOY about it?
Your answer
What did you DISLIKE about it?
Your answer
How may days do you currently train?
1
2
3
4
5
days
Clear selection
When I workout....
I'm there to work and get out
I want to have a laugh and break a sweat
I'm there to learn and get some work done
Each session is a step towards getting better
Other:
Clear selection
What do you value most about hiring a coach?
Accountability
Expertise
Motivation
Learning
Enjoyment
Clear selection
How do you learn best?
Verbal feedback. Please explain.
Hands on feedback. I sometimes need to be guided.
Visual feedback
Let me try it. Trial & error works best for me.
A combination of the above
Clear selection
What is your current training goal & why?
Your answer
What would success look like to you in the short term (<3 months) and long term? (> 12 months)
Your answer
What services are you interested in
Personal Training
Small Group
Individual Training [Program written for you to do on your own]
Virtual Training [via Zoom]
In Home Training
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How much time are you willing to commit to your training?
1 hour per week
2-3 hours per week
3-5 hours per week
5+ hours per week
Other:
Clear selection
Health History
In the last three months what physical activities have you been involved in?
Your answer
Do you have any previous injuries of note that impact your training?
Yes
No
Clear selection
If Yes, please elaborate
Your answer
How many hours of sleep per night do you get on average?
8+ hours
6-8 hours
4-6 hours
less than 4 hours
Clear selection
How would you rate your nutrition quality?
Very Poor
1
2
3
4
5
Very Good
Clear selection
Is nutrition something you would like to address at a later date?
Yes
No
Let me think about it
Clear selection
Is there anything else you'd like to share that would help your coach when designing your training program?
Your answer
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