Coaching Intake Form | Acacia Fruit

First Name

Last Name

Phone

Date of Birth

Age

Where Do You Live?

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?

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?

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?

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?

Submission Complete!