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intake form
Please be as detailed as possible when filling out this form!
Name
*
First Name
Last Name
Phone
(###)
###
####
Email Address
*
Age
*
Height
*
Weight
*
What do you do for a living?
*
What is your activity level at work?
Sedentary (seated all day)
Moderate (light activity such as walking)
Heavy (very active such as labor work)
What are your current health & fitness goals?
*
Weight loss
Weight gain
Improve dietary intake
Reduce health risks
Increase strength & muscle mass
Repair relationship with food
Do you currently track your dietary intake?
*
Yes
No
If yes, how many calories are you consuming and how is your body responding to that intake?
What does a typical day of eating look like for you?
*
Briefly discuss meals, snacks, and your eating patterns.
Do you have any food allergies or intolerances?
*
Yes
No
If yes, please list them.
Which fruits do you enjoy to eat?
*
Check all that apply.
Apples
Avocados
Bananas
Berries
Cherries
Grapes
Kiwi
Melons
Pineapple
Pears
Which vegetables do you enjoy to eat?
*
Check all that apply.
Asparagus
Beans
Beets
Broccoli
Brussels sprouts
Carrots
Cauliflower
Celery
Cucumbers
Egg Plant
Greens
Mushrooms
Onions
Potatoes
Peas
Salad greens
Sweet potatoes
Squash
Zucchini
Which proteins do you enjoy to eat?
*
Check all that apply.
Eggs
Beef
Bison
Chicken
Cheese
Pork
Seafood
Shellfish
Tofu
Turkey
Venison
Yogurt
Please list foods you dislike or avoid.
*
Do you currently exercise on a regular basis?
*
Yes
No
If yes, how often do you exercise?
1-2 days/week
3-4 days/week
5-6 days/week
6+ days/week
Which types of exercise do you enjoy?
*
Check all that apply.
Aerobics
Circuit based training
Group fitness classes
Pilates
Plyometrics
Strength training
Yoga
When do you prefer to workout?
*
Morning
Afternoon
Evening
Do you drink alcohol?
*
Yes
No
If yes, how many drinks do you have per week?
1-2 drinks / week
2-4 drinks / week
4-6 drinks / week
6+ drinks per week
Do you currently smoke cigarettes or vape products?
*
Yes
No
Do you have any existing medical diagnoses or underlying health conditions?
*
Yes
No
If yes, please list them.
Do you have any history of injuries?
*
Yes
No
If yes, please list them.
Are you currently taking any medications?
*
Yes
No
If yes, please list them
Are you currently taking any supplements?
*
Yes
No
If yes, please list them
Are you currently a student?
*
Yes
No
Are you active military or veteran?
*
Yes
No
Are you ready to invest in your health?
*
Yes
No
When do you want to get started?
*
MM
DD
YYYY
Thank you!
