Online Intake Form
This is your comprehensive client information form. With this form, we will ask you to provide some relevant personal information. The answers to these questions are essential in order to allow us to design an optimized individual fitness program for you. Please answer all questions in the most accurate manner possible while being as concise as possible. Disclaimer: Please recognize the fact that it is your responsibility to work directly with your physician before, during, and after seeking fitness consultation. As such, any information provided is not to be followed without the prior approval of your physician. If you choose to use this information without the prior consent of your physician, you are agreeing to accept full responsibility for your decision. Milwaukee Wisconsin 53202.
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Email *
Are you looking to train online or in-person?
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Preferred contact method. (Email or Phone) If phone place number below. *
What is your name? *
Are you Male or Female? *
Approximate Body Fat Percentage (If you don't know give an estimate) *
What is your weight? *
What is your height? *
What is your date of birth (month/day/year)? *
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What do you do for a living? *
What is the activity level at your job? *
If you follow a more regular schedule, when do you work? *
Are you on any specific food/diet plan at this time? If yes, please list: *
How would you describe your current nutritional habits? *
Do you take dietary supplements? If yes, please list: *
Other food/nutritional issues you want to include (food allergies, mealtimes, etc.) *
How would you rate your current level of fitness? *
Are you training consistently? *
On average how many hours a week do you exercise? *
How many days a week are you willing to commit to training? *
Can you describe your specific, short-term goals (within the next 12 weeks)? *
Can you describe your specific long-term goals (over the next year)? *
If you have any injuries, please list them. *
If you are on any medications, please list them. *
If you have any diagnosed health problems, list the conditions *
How many hours a day do you sleep? *
Aside from financial cost, is there anything that would stop you from embarking on a fitness program? *
What date are you looking to start your fitness journey? *
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If there is any other information you think relevant to your program design, please share it with us below. *
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