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New Client Intake Form
First Name
Last Name
Email
Phone
Date of Birth
Age
Gender
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Where Do You Live?
Medical History
1) How Tall Are You?
2) How much do you weigh?
3) Do you have any medical restrictions that limit your ability to participate in physical exercise?
4) Please list any significant injuries or surgeries that you've had.
5) Who is your Primary Care Provider?
6) Are you taking any perscription medications? If so, please list them here.
7) Do you use any recreational drugs? If so, please list them here.
8) Do you drink alcohol? If so, approximately how many drinks do you consume per week?
Exercise, Nutrition, & Lifestyle
9) Briefly describe your current exercise routine.
10) Briefly describe what a typical day of eating looks like in your daily life.
11) What are your current fitness goals?
12) What are your nutritional/dietary goals?
13) Have you attempted to make these changes to your fitness and/or diet in the past? If so, what worked, and what didn't work?
14) How committed are you to accomplishing these health and fitness goals? (1-10)
Choose an option
15) How much time do you have to dedicate to these goals? (1-10)
Choose an option
16) What challenges or barriers-to-success do you expect to face in seeking to accomplish these health and fitness goals?
17) Are there any specific areas that you want to focus on during your health coaching sessions?Â
18) Is there any other information that you'd like to share at this time or that you feel your health coach should know before your next meeting?
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Submission Complete!
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