Client Intake Form
Please fill out this form with as many honest details as possible. This will help me get to know you and your goals.

Set aside 10-15 minutes to complete the form. Once it has been submitted, please allow up to 48 hours for a response from me. Keep an eye on your inbox!

Note that all the information provided will remain confidential. 

By completing and submitting this form, you confirm that a licensed healthcare provider has cleared you for physical activity and exercise. You understand that online coaching and fitness guidance are not a substitute for medical advice, and you participate voluntarily and at your own risk.  
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Which service were you interested in? *
Full Name *
Date of Birth *
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Gender
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Height (in cm or inches)
Weight (in kg or lbs)
Mobile phone number *
Email address *
Physician Name and Phone Number
Emergency Contact Name and Phone Number
Tell me about your fitness goals! What would you like to achieve? What have you achieved already that you are proud of?
What are some key factors holding you back from achieving those goals?
What exercise activities do you currently take part in?
How many days per week do you get at least 60 minutes of moderate-intensity exercise?
On a scale of 0 to 10, how important are the following fitness goals to you?
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1
2
3
4
5
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10
Weight loss
Muscle gain
Sports performance
Health improvement
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On a scale of 0 to 10, do you consider your overall diet to be healthy?
Not Healthy
Very Healthy
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On a scale of 0 to 10, how much water do you drink on average per day?
Less than a cup
More than 4 litres
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Are you currently following any kind of diet? If so, what and for what reasons?
How would you rank your daily salt intake?
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How would you rank your daily sugar intake?
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How would you rank your daily fat intake?
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How would you rank your daily intake of processed foods?
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On a scale of 0 to 10, how effectively do you control temptations for junk food?
Not Effective
Very Effective
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How many alcoholic drinks do you consume per week?
Do you consume caffeinated beverages (coffee, tea, soda, energy drinks)? How many per week?
Do you feel like you get enough sleep and wake up rested each day?
On a scale of 0 to 10, how would you rate your average stress level?
Very Low
Very High
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What techniques do you currently use to manage stress?
Do you smoke tobacco, marijuana, or use a vaporizer?
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What is your occupation?
Does your occupation require extended periods of sitting?
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Does your occupation require repetitive movements?
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Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?
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Do you partake in any recreational physical activities (golf, skiing, etc.)? If yes, please explain.
Do you have additional hobbies (gardening, fishing, music, etc.)? If yes, please explain.
Please list any past musculoskeletal injuries.
Please list any past surgeries.
If you’ve experienced injuries/surgeries, were they properly rehabilitated and did you receive clearance from a doctor?
Do you have any chronic health conditions (cardiovascular disease, pulmonary disorders, hypertension, diabetes, cancer, etc.)?
Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity?
Is there anything else you would like me to make note of?
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