Client intake form

1
Name
First Name
Last Name
2
Birthday* This field is required.
Date
Month
Day
Year
3
Email
example@example.com
4
Phone Number
Area Code
Phone Number
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
I am a:
Woman
Man
7
My Age:
8
Current Weight (Weigh upon waking)
9
Height
10
Daily Activity Level:
Sedentary: Most of the day sitting (desk job, limited movement)
Light Activity: Spend most of the day on your feet (Retail, teacher)
Active: Higher level of mobility (waitress, mailman)
Very Active: Manual labor (landscaping, construction, foot messenger)
11
Number of days/Week of Weight Training:
12
Minutes per Weight Training Session:
13
Number of Days/Week of Cardio
14
Minutes per Cardio Session
15
Training Split: Describe your week of training (body parts worked/day, rest periods between sets, types of cardio, etc).
16
Intensity level during weight training
Light: normal heart rate/breathing is easy, not sweating, can hold a conversation/sing, ~50-60% max heart rate
Moderate: Heart rate has increased/breathing becomes more difficult, starts sweating ~ 10 minutes into activity/can talk, but not sing, ~61-70% max heart
High:Heart rate has become rapid, breathing is deep and rapid, starts sweating ~3-5min into activity/difficult to speak in complete sentences, ~71-80% Max heart Rate
Extreme: Heart rate is close to maximum, breathing is very short, excessively sweating, cannot get more than a word or two out, think sprint intervals, bootcamp, ~81-90% Max heart rate.
17
Wake Time:
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
18
Bed Time:
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
19
Workout Time:
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
20
Occupation:
21
Times it is difficult/impossible to consume a meal:
22
Meals per day:
23
List any medications you take:
24
List all supplements you regularly take:
25
List any injuries:
26
List any food allergies:
27
Foods you love: (healthy choices, proteins, carbs, fats, veggies):
28
Foods you strongly dislike (healthy choices, proteins, carbs, fats, veggies):
29
List some favorite desserts/cheat meals:
30
Level of Fitness
Beginner
Intermediate
Advanced
31
Have you ever worked with a nutrition coach?
yes
No
32
Have you competed before?
yes
No
33
Which organization(s) and category(s)do you compete:
34
List Most recent competitions and placings:
35
What was your last stage weight or weight that you were in your best shape?
36
What are your goals(be as specific as possible)
37
Motivation behind your goals (why do you want to achieve?)
38
what show/date do you wish to compete?
39
Please provide a typical day's Food LogList meals with food items and portion sizes
40
Please provide before pictures (Front, side, back)
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