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Client Intake Form.
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Name
*
First
Last
Date of Birth
*
Email
*
Address
Phone
Emergency Contact
Relationship
Emergency Contact Phone
How did you learn about us?
Do you currently exercise regularly?
Yes
No
Occasionally
If yes, what type, and how often?
On a scale of 1 to 10, how would you describe your physical fitness level? (1 = not fit at all, 10 = very fit)
Selected Value:
1
What are your biggest challenges, if any, to maintaining your physical fitness or overall health? (Example: time, motivation, finding activities, etc.)
On a scale of 1 to 10, how healthy do you consider your eating habits? (1 = not healthy at all, 10 = very healthy)
Selected Value:
1
Please describe your typical daily diet, including any dietary restrictions
Do you smoke?
Yes
No
Occasionally
Former smoker
Do you drink alcohol?
Yes
No
Occasionally
If yes, how many drinks per day or week?
On a scale of 1 to 10, how would you describe your stress level? (1 = not stressed at all, 10 = very stressed)
Selected Value:
1
What are your biggest stressors? (Example: work, family, health, relationships, etc.)
On average, how many hours per night do you sleep?
Would you describe it as restful?
Yes
No
Some nights
What is your occupation?
What do you hope to achieve through your program? (Check all that apply)
Manage a chronic condition
Lose weight
Improve sleep
Reduce pain
Gain weight
Healthy aging
Improve muscular strength/tone
Improve nutrition
Lifestyle change
Improve flexibility
More energy/vitality
Mindfulness
Recover from injury/illness
Reduce stress
Other
If Other, please specify
Please mark any of the following conditions you may currently have:
High blood pressure
Diabetes
Joint replacement
Osteoporosis
Heart condition
Balance issues/dizziness
Recent surgery
Arthritis
Recent weight gain or loss
Shortness of breath
Chronic pain
Anxiety/Depression
Overweight or Obesity
Neck injury
Other
If Other, please specify
Consent
*
I agree to the consent statement above.
I consent to the use of the information provided for the purpose of health coaching and personal training/exercise instruction. I certify that my answers above are accurate to the best of my knowledge, and understand that inaccurate information could affect my health and safety. I understand that health coaching and personal training do not guarantee specific outcomes, and that results depend largely on my own actions and consistency.
maintaining may On
Signature (type your full legal name)
Date
Submit