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New Client Intake Form
Date of Birth
Gender
Occupation
What is the main reason you are wanting out of this process?
Training Information
Please fill this in if you are looking for training programming otherwise continue down further for nutrition.
What are your fitness goals:
Will you be performing any other forms of exercise other than strength training?
How often per week are you wanting to workout?
How long are you wanting to workout each session?
Please list any medical conditions, illnesses or injurys:
Do you follow a specific diet?
What gym equipment do you have access to?
Please list any supplements you are taking:
Please describe in as much detail as possible your current training program or email it through:
What is your weight? Height? Estimated Body Fat Percenage (if known):
Nutrition Information
What are your nutrition goals:
Do you have any current medical illness/conditions? Medications?
Family History: Does anyone in your immediate family have any of the following?
Diabetes
Obesity
Heart Conditions/Strokes
Do you suffer from any of the following?
Aches & pains in joints
Aches & pains in muscles
Back problems
Bloating
Digestive issues
Stomach pain
Blood pressure issues
Heart problems
Irregular Periods
Headaches or migraines
Skin Problems
Prone to sickness/illness
Please provide as much detail about any of the boxes ticked above:
What would you rate your stress levels out of 10 (10 being highest):
Sleep: Do you have issues falling asleep/staying asleep? How much do you sleep each night?
Do you take any food/vitamin supplements (including herbal remedies)? Please list including doses
Do you eat regular meals?
Yes
No
Are you on a specific diet?
Vegan
Vegetarian
Gluten Free
Low Carb
Keto
Dairy Free
How much water do you consume daily?
Other liquids consumed daily, soft drinks, energy drinks etc.
How much coffee do you consume daily?
How much alcohol do you consume daily? Or weekly?
Do you suffer from any food allergies/intolerances? Please list
What is your current exercise regime?
What is your typical breakfast?
Typical Mid Morning Snacks?
What is your typical lunch?
Typical afternoon snacks?
What is your typical dinner?
Typical dessert?
Are there any times of the day when you tend to feel particularly hungry e.g. mid-morning, mid- afternoon?
Do you enjoying cooking? Do you meal prep? Do you prefer simple foods or more recipe based cooking?
Submit
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