Client Intake Form Name * First Name Last Name Email * Phone Number * Where do you currently live (city, state, country)? * Marital Status * Single Dating Engaged Married Separated Divorced Widowed Do you have children? (If so, please include their ages.) * Your Age * Your Birthday * Emergency Contact's Name, relationship to you, and their phone number * Height * Current Weight * Any Current Medications * Any current medical conditions/diagnosis * On average, how many hours of sleep do you get per night? * What is your morning routine? * What is your evening routine? * What do you do to relax? What do you enjoy doing in your free time that fills you up? * Are there any habits that you’d like to start incorporating into your life? Are there any habits you’d like to stop? * How many meals do you eat per day? Snacks? * At what time do you eat each of your meals? * What do you typically eat for breakfast? Lunch? Dinner? Snacks? * How much water do you drink per day? * Do you drink coffee? If so, how many cups per day? * Do you drink alcohol? If so, how much/how often? * Do you take any vitamins or supplements? If so, which ones? * Do you have any allergies or food sensitivities/intolerances? * What foods do you like? * What foods do you dislike? * Current cardiorespiratory fitness level (how many times/week, duration of session, intensity): * Current resistance training level (how many days/week, what kind of split, intensity, duration of sessions): * Any other fitness activities you’re involved in: * Where do you plan to workout? Home? Gym? Both? * What workout equipment do you have available to you (machines, dumbbells, resistance bands, etc…)? * On average, how many steps do you get per day (if known): * What type of cardio do you enjoy? (ie: walking, biking, running, swimming, dancing, kickboxing, etc…) * What is the minimum amount of time you can devote to exercise in this season of life (how many days/week, how much time/day)? * What is the maximum amount of time you could commit to exercising in this season (how many days/week, how much time/day)? * How much time are you willing to devote to exercise right now? * What are your specific health and wellness goals (ie gain weight, lose weight, gain muscle, get toned/muscle definition, improve cardiovascular endurance, gain speed/power/agility, flexibility/mobility)? * What do you struggle with the most, and what do you want the most help with? * What is your “why”, or your reason/motivation for making a change? * How committed are you to achieving your goals? * What will your life be like when you reach your goals? * How will you celebrate when you reach your goals? * Anything else you want me to know: * Do I have your permission to share your progress pictures with your face blurred out on my online platforms? Yes - use my first name only Yes - share anonymously No Do I have permission to occasionally share screenshots of our messages about your wins and progress on my online platforms? Yes - use my first name only Yes - share anonymously No Do I have permission to contact you through your personal phone number about coaching calls, your fitness program, your progress, etc? Yes No Thank you so much for submitting your client intake form! Your answers have been sent to Madison. She will be in touch with you soon! Congratulations on taking this next step in your health journey.
