Client Intake Form

01 / Personal Information

Full Name

Preferred Name

Age

Date of Birth

Phone Number

Email Address

City / State

02 / Body Stats

Current Weight

Height

Goal Weight

Clothing Size

03 / Health & Medical

Health Conditions (select all that apply)

Injuries, surgeries, or limitations?

Current medications?

Pregnant or trying to conceive?

Number of children

04 / Nutrition

What does a typical day of eating look like?

Dietary Restrictions (select all that apply)

Glasses of water daily?

Do you drink alcohol?

Foods you absolutely will NOT eat

Do you meal prep?

Do you cook at home?

05 / Fitness & Lifestyle

Gym membership?

Gym name

Equipment Available (select all that apply)

Days per week you can commit

Time per session

Preferred Workout Time

Current Activity Level

Types of exercise you enjoy or want to try

06 / Your Goals

Top Goals (select up to 3)

Your Number One Goal This Month

What Has Stopped You Before?

Timeline Goal

Current Motivation Level

07 / Accountability

How Do You Handle Hard Days?

What Keeps You Going When Motivation Is Low?

Preferred Check-in Method

Best Check-in Day

By submitting this form you confirm the information is accurate to the best of your knowledge. Your coach is not a licensed medical provider. Always consult your physician before starting any new fitness or nutrition program.