Client Intake Form Contact Information Name * First Name Last Name Age * Gender * Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Instagram Handle *if applies Emergency Contact Emergency Contact + Relationship * Emergency Contact Phone Number * Medical History Are you currently under the care of a physician? If yes, please provide details: Do you have any medical conditions I should be aware of? If yes, please specify: * Are you taking any medications? If yes, please list: * Do you have any allergies? If yes, please specify: * Have you had any surgeries in the past? If yes, please specify: * Fitness Background Have you worked with a personal trainer before? If yes, please describe your experience: Do you currently exercise? If yes, what type of exercise do you do and how often? What are your fitness goals? Are there any specific areas of your body you want to focus on? Are there any specific areas of your body you want to focus on? Lifetsyle On a scale of 1-10 (10 being VERY stressed) how would you rate your overall stress levels throughout the day? How much sleep do you get per night? What is your occupation? How many hours a week do you work? How would you describe your daily activity level? Do you smoke? Do you drink alcohol? If so, roughly how much per week? Special occasion only? Nutrition Can you tell me about the types of food you're currently eating? What does your week to week meal plan look like? Do you have any specific dietary restrictions or preferences? Are you currently working with a nutritionist or following any specific plan? Do you notice yourself getting fatigued quickly during workouts and/or throughout the day at certain times? How many grams of protein do you think you are eating daily on average? How much water/electrolytes are you consuming per day? Other Is there anything else you want to share with me or ask? Why did you actually reach out to me about training? Give me the gritty reason - no BS. Thank you so much!