Client Intake Form

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Client Intake Form

Name *

Date of Birth *

YYYY

Email *

Phone Number *

Do you have a preferred method of contact? *

Phone

Text

What are you current fitness goals? Please be as specific as possible. *

Do you currently exercise or follow any other programs? *

Do you have any medical concerns or previous injuries that may affect your ability to exercise? *

Are you currently taking any supplements? If yes, please list what you are currently using. *

How would you rate your current diet? *

Poor

Excellent

Do you currently track your daily food intake? *

Yes

Occasionally

Do you have any eating habits that are concerns for you? If yes, please explain. *

Do you drink water daily? *

Yes

How often do you consume alcohol? *

Never

Rarely

Occasionally

Often

Do you smoke?

Yes

Clear selection

Do you have a consistent sleep routine?

Yes

Clear selection

Do you feel you get a proper amount of sleep each night?

Yes

Sometimes

Clear selection

Do you have any additional comments or questions you would like us to know?

Submit

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