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Free Fat Loss Guide
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Coaching
Free Fat Loss Guide
Articles
CLIENT INTAKE FORM
Name
*
First Name
Last Name
Email
*
Shipping Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Shirt Size
*
Start Date
*
START DATE MUST BE AT LEAST 3 BUSINESS DAYS AFTER COMPLETION OF PAYMENT AND WAIVERS
MM
DD
YYYY
Gender
*
Male
Female
Age
*
Height
*
Weight (lbs)
*
Body Fat Percentage
*
Rate and describe your level of readiness on a scale of 1-5 (see description of scale below)
*
1 = I am not ready or willing to change much in order to reach my goals. 5 = I will do anything it takes to reach my goals as effectively and efficiently as possible.
What is your current activity level?
*
Sedentary = office job with standard life chores / step count below 7,500 Somewhat Active = on your feet part of the day with standard life chores / step count 7,500 - 9,999 Active = on your feet and moving most of the day / step count 10,000-12,500 Very Active = involved with manual labor most of the day / step count over 12,500 with intensive movement
Describe your current training program / exercise routine in as much detail as possible.
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How often are you willing to train for optimal results?
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How much time are you willing to dedicate for each workout?
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How many steps are you willing to get each day for optimal results?
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Do you have access to a barbell and weight plates? If so, please list the increments of the weight plates you have access to.
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Do you have access to dumbbells? If so, please list the lightest and heaviest dumbbells you have access to along with the weight increments between each set of dumbbells.
For example, "I have dumbbells that range from 10-50 pounds in 5 pound increments."
Do you have access to...
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Select all that apply
A squat cage or squat rack?
A bench?
An adjustable bench?
A leg press?
A seated leg curl machine?
A lying leg curl machine?
A leg extension machine?
A lat pulldown machine?
An assisted pull-up/dip machine?
Cables?
Bands?
Describe your diet in as much detail as possible.
*
List all supplements you are currently taking.
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How much alcohol do you drink on a weekly basis?
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How much caffeine do you consume per day?
*
Describe your stress.
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What stressors are you currently dealing with? Are you always stressed? How do you manage your stress?
Describe your sleep in both quality and quantity.
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This needs to be as detailed as possible. When do you go to bed? When do you wake up? Are you asleep through the night? Are you in a deep sleep? Do you fall asleep quickly?
Describe your energy levels throughout the day.
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Do you have any illnesses, pain, and/or movement limitations?
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What medications are you currently taking?
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Tell me about yourself! What do you enjoy? Who do you like spending time with and why? What are your hobbies? What's your favorite food? Your hottest take? What makes you smile, laugh, cry, sing? I'd love to know you as a person, not just a client. You can answer those questions and/or include anything you'd like!
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Please include any additional information you think I need to know.
Thank you!
