Intake Form

INTAKE FORM

Please complete the following information as completely as possible.

Name *

Email *

Phone *

Goals

Please list 3 reasons you want to get healthier or specific goals you want to reach:

Diet

What types of food do you eat every day? *

Do you know how many calories/carb/fat/protein that you eat every day? *

Yes

Calories

Carbs

Fat

Protein

What time of day do you normally eat?

Breakfast

Lunch

Snack

Dinner

Snack

Other Meal

Please list foods you like:

Please list foods you dislike/cannot eat:

What supplementation and vitamins do you take?

Exercise

Do you require a doctor’s release in order to exercise? *

Yes

What cardiovascular exercise do you normally do (if any) including what machines normally use? Do you run? Bike? How many minutes or how far? Days per week?

Do you weight train? *

Yes

How often?

What muscles are your strength and what are weaknesses or areas you feel you need to focus on?

What equipment or gym do you have available to use?

Daily Routine

What time do you:

Wake Up

Workout

Cardio

Sleep

Medical Concerns

Prescription meds:

Injuries

Surgeries

Anything else that you think is important for me to know:

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