New Online Training Client Intake Form

Let's start with the basics.

What is your first and last name?

How do you identify?

How do you identify?
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How would you like me to refer to you?

How would you like me to refer to you?
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When is your birthday?

What is your phone number?

What is your email address?

What is your address?

Let's dive deeper.

What are your goals?

What are your goals?

List your top 3 concerns you have about your health, eating habits, fitness, and/or body.

Why did you choose those 3?

What are you willing to work on to reach your goals?

What aren't your willing to do to reach your goals?

What are the top 3 things you're interested in changing?

Please list all of the obstacles you feel like you're facing when it comes to achieving your goals?

What kind of exercise do you currently do and how often?

What's your health like?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?

What, if any, significant medical condition(s) and/or injuries have you been diagnosed with (currently or in the past)?

What, if any, specific health concerns, such as illnesses, pain, and/or injuries do you have?

What, if any, medications, either over-the-counter or prescriptive, are you taking?

On a scale of 1-10, how would you rank your health right now?

0 being "it totally sucks" and 10 being "I should be my own species I'm so healthy"
On a scale of 1-10, how would you rank your health right now?

Disclaimer

It is your responsibility to work directly with your health care provider before, during, and after seeking nutrition, fitness, and behavior change help. Any information provided by (YOUR BUSINESS NAME) is not to be followed without prior approval from your doctor. If you choose to move forward with the information provided without your doctor's approval, you agree to accept full responsibility for your decision.
By clicking the yes button below, you're agreeing to the disclaimer and that all of the information you've provided above is accurate and up to date to the best of your knowledge.
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