New Client Intake Form

Name

First Name Last Name

Email

example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number

What are you looking for help with?

Nutrition Training Workouts Competition Prep

How did you find out about Philosophy?

What is your occupation?

Please choose which best describes you.

Weight Loss Goal Maintain weight but change body composition Weight Gain

Why have you chosen to hire a Nutrition Coach/ Personal Trainer?

What are some obstacles (behaviors, stress, activities, etc) that you foresee impeding your success?

Have you developed any plans to overcome these obstacles?

What best describes you activity level?

Sedentary (sitting more than 7-8 hours during the work day) Moderately Active (Sitting 6 hours and on you feet at least 2 hours during the work day) Active (On you feet more than 5 hours per day Very Active (on your feet more than 6 hours a day and periodic lifting during the day)

Have you had recent blood work done?

Do you have any allergies that you are aware of?

Are you on any medications? Please list them.

How do you monitor your eating habits?

Do you feel that you eat a healthy diet most of the time?

How much water do you drink per day?

Do you consume coffee?

yes no

Do you consume energy drinks?

yes no

Do you drink soda?

yes no

Do you drink alcohol?

yes no

What type and how frequently?

Describe a typical day in your diet from when you wake up from when you go to sleep.

How do you feel about diets. Have you tried any fad diets?

Do you take any supplements? Please list them.

Do you have any specific cravings? If so please list them.

How many hours of sleep do you typically get?

What time do you normally wake up?

When do you usually consume your first meal of the day?

Do you struggle with structure?

Do you have any prior or current eating disorders? Please describe.

Do you train or do cardio on an empty stomach?

Have you been exercizing consistently for 3 months?

How long have you been exercising?

When were you in the best shape?

Have you begun an exercise program in the past?

Were you successful?

What (if anything) stopped you from continuing?

What is different this time?

Do you do any weight training?

yes no

If so, how often and for how long?

Do you do any cardiovascular training?

yes no

If so, how often and for how long?

Realistically, how long are you willing to exercise?

How long are you willing to spend at each exercise session?

Please list any other sports/activities that you are involved in:

Do you have any injuries or prior surgeries? Please list:

Are there any specific exercises that you are unable to perform. Please list and reason why.

What are you looking for in a personal trainer/ nutrition coach?

What motivates you?