Comprehensive Initial Intake Form
Health and Wellness Profile
Date of Birth
Prefer not to say
How do you prefer to be contacted?
Which method of contact do you prefer?
Current Body Weight (in pounds)
Current body fat % (if known)
50% or over
Method used to determine body fat
Bio-electrical Impedance (BIA)
DEXA / Bod Pod
Caliper Method - 3 site
Caliper Method - 7 site
Tell us more about yourself.
Simple enough, Who are you? (hint it's a loaded question) By learning more about your lifestyle and your habits, we can take better care of you and determine which coaching service is a good fit for your goals and individual needs. No need to get into a novel here just 4 or 5 sentences to describe where you're at in your life will help.
What do you want to achieve working together?
In general, what are your goals? Check all that apply.
Improve physical fitness
Improve athletic performance
Get control of eating habits
Have more daily energy and vitality
Improve mental focus
Improve happiness / sense of fullfillment
Right now, what things are holding you back from improving these things you've listed above?
Please list all of your concerns about your health, eating habits, fitness, and/or body.
Out of all of the above concerns, which ones (top 3) feel most important/urgent?
Why do they feel most urgent to you?
What do you expect from working together?
What do you expect from me as your coach?
What do you think we expect from you?
What are you prepared to do to work towards your goals?
What have you already tried to change?
Have you tried anything in the past to change your habits, your health, your eating, and/or your body? If so, what?
Which of those things worked well for you? (Even if you might not be doing it right now.)
Which of those things didn't work well for you? Or maybe it worked for a short while but stopped working?
Right now, how would you rank your overall eating/nutrition habits?
Why did you rate yourself that?
Are you regularly active in sports and/or exercise?
If so, approximately how many hours per week?
20 or more
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