SELF-LOVE AND FITNESS INTAKE FORM
Client interest form - this form allows us to put together an initial assessment of client-program fit and is also used as the intake form. That said, this form does not create a client-practitioner relationship. All client information is held under the strictest confidence.
First and last name *
E-mail address *
Phone number *
Country *
Province or State *
Age *
Weight *
Height *
Approximate body fat percentage *
Nutrition and fitness goals *
Required
Preferred method of grocery shopping? *
Favourite take-out restaurant and overall comfort-food style meals? (I am asking so that we can look at healthified versions of your favourite comfort foods, this may not be needed, but depending on your goals it may be helpful). *
Amount of weights you can lift in pounds - either using one hand with dumbbells or both hands with a kettlebell? *
Number of Litres of water per day? *
Current supplements? *
Required
Current level of fitness and fitness routine? (Even if your chosen consultation may be for nutrition only - your exercise patterns are relevant). *
How often do you train and would you like to train more often? *
Please describe and list any fitness equipment you currently own. If you own weights, is it barbells, kettlebells, or dumbbells, and how many pounds? Do you have a flat or incline bench? Resistance bands? Etc. *
Journaling prompt 1: What do you REALLY want your wellness, health, fitness, body, and nutrition to look like / feel like? No details to hold back. Is it investing in making meal prep easier, is it how you want to feel/look? Feel free to answer in bullet-form. You will only have to journal this one-time (aside from tracking 3 days of macros) unless you are part of our journaling platform offered to members. *
Journaling prompt 2: What does your relationship with food look like, what did you get fed growing up, and what does food do for you? Does it serve any emotional needs? Is it something that you gravitate to for comfort? Do your eating habits change frequently? Is food viewed as a source of fuel, entertainment, both? Feel free to answer in bullet-form. You will only have to journal this one-time (aside from tracking 3 days of macros) unless you are part of our journaling platform offered to members. *
Do you have a history of respiratory or other serious illnesses that would require you to get clearance from a physician before starting an exercise program? *
Do you have a history of kidney issues? *
By participating in this program, you have read the following disclaimer and agree: This program and its content is not intended to diagnose or treat any diseases. Always consult with your primary care physician or licensed healthcare provider for all diagnosis and treatment of any diseases or conditions, for medications or medical advice as well as before changing your health care regimen. *
Willingness to leave a public review if satisfied with the program should you choose to enroll? *
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