Client Intake Form
Email address *
What brought you here, why do you want to work with me? *
What are some outcome based goals you want to achieve? These are goals that will be a byproduct of your hard work in the coming weeks. *
Have you ever had any injuries/do you presently have any injures that would affect your training? *
If you answered yes or maybe, please explain.
Do you have gym intimidation? What would you say your level of fitness is, with 1 being zero experience at all and 10 being experienced and confident with a variety of exercises. *
Has your doctor ever said that you have a heart condition? *
If you answered yes, please explain what your condition is.
Do you ever feel pain in your chest while at rest and/or while performing physical activities? *
Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? *
If you answered yes to the previous question, please explain the situation.
Has your doctor ever diagnosed you with a chronic health condition? *
If you answered yes, please explain what your condition is.
Please list all medications you are currently taking. *
Do you have any food allergies or aversions? *
If you answered yes, list your allergies or aversions.
If I presented you with a list of foods and asked you to tell me which foods were a protein source, a carb source and a fat source, would you feel confident in your answers? *
Are there any foods you're afraid to eat for any reason at all? *
If you answered yes or somewhat, what foods are you afraid of? Do you know why?
What is your favorite form of exercise? *
What is your least favorite form of exercise? *
Is there anything specific you want to work on that I should know about? *
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