New Client Intake

Name *

Name

First Name

Last Name

tell me more about yourself.
by learning more about your lifestyle and your habits, I can take better care of you and make sure coaching is a good fit for your goals and individual needs.

Date of Birth

staying in touch

Phone

Phone

(###)

###

####

How do you prefer me to contact you?
Email
Phone
Skype or other video chat
Text
Other (please specify)

what do you want?

In general, what are your goals? Check all that apply.
Lose weight/fat
Gain weight
Maintain weight
Add muscle
Improve physical fitness
Look better
Feel better
Have more energy and vitality
Get control of eating habits
Get stronger
Physique competition/modeling
Improve athletic performance

Please list all of your concerns about your health, eating habits, fitness, and/or body.

Out of all of the above concerns, which ones feel most important/urgent?

Why?

what do you expect?

What do you expect from me as your coach?

What are you prepared to do to work towards your goals?

what do you want to change?

Have you tried anything in the past to change your habits, your health, your eating, and/or your body?
Yes
No

If so, what?

Which of those things worked well for you? (Even if you might not be doing it right now/)

Which of those things didn’t work well for you?

How, specifically, would you like your habits, your health, your eating, and/or your body to be different?

Have you already made changes to your habits, your health, your eating, and/or your body recently?
Yes
No

If so, what?

If you were to consider making further changes to your habits, your health, your eating, and/or your body, what might those be?

Until now, what has blocked you or held you back from changing these things?

Right now, how would you rank your overall eating/nutrition habits?
Horrible
Somewhat horrible
Middle of the road
Somewhat awesome
Awesome

Why?

Are you regularly active in sports and/or exercise?
Yes
No

If so, approximately how many hours per week?
Fewer than 5 hours
5-9
10-14
15-19
20 or more

What types or sports and/or exercise do you typically do?

Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
Fewer than 5 hours
5-9
10-14
15-19
20 or more

What other types of movement and/or activities do you do?

What’s around you?

Who lives with you? Check all that apply.
Spouse or partner
Roommate(s)
Child(ren)
Pet(s)
Other family (e.g. parent, grandparent, sibling, etc.)

Do you have children?
Yes
No

If yes, how many and what are their ages?

Who does most of the grocery shopping in your household Check all that apply.
Me
Spouse or partner
Roommate(s)
Child(ren)
Other family

Who does most of the cooking in your household? Check all that apply.
Me
Spouse or partner
Roommate(s)
Child(ren)
Other family

Who decides on most of the menus/meal types in your household? Check all that apply.
Me
Spouse or partner
Roommate(s)
Child(ren)
Other family

The people and things aroundyou support health, fitness, and/or behavior change.

The people and things aroundyou support health, fitness, and/or behavior change.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

What’s your health like?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?
Yes
No

Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?
Yes
No

Right now, are you taking any medications, either over-the-counter or prescription?
Yes
No

On a scale of 1-10, how would you rank your health right now? (1 being worst, 10 being awesome)

1

2

3

4

5

6

7

8

9

10

Why?

How are you spending your time?

In an average week, how many hours do you spend in paid employment?

In an average week, how many hours do you spend at school or doing school work?In

In an average week, how may hours do you spend traveling and/or commuting?

In an average week, how many hours do you spend taking care of others? (e.g. children, person with a disability, older person)

In an average week, how many hours do you spend doing other unpaid work? (e.g. housework, errands)

In an average week, how many hours do you spend volunteering?

Adding up all these things, how many total hours per week do you spend doing all these activities?

On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness? (1-my life is panicked and insane, 10-my life is perfectly calm and relaxed)

1

2

3

4

5

6

7

8

9

10

How is your stress and recovery?
Think about all the activies you’re involved in (e.g. work, school, caregiving, housework, travel). Then assess as best you can

Given all the demands of your life, what is your typical stress level on an average day?

1-No stress, 10-Extreme stress

1

2

3

4

5

6

7

8

9

10

On average, how many hours per night do you sleep?

4 or fewer

5

6

7

8

9

10 or more

How do your normally cope with your stress?

How ready, willing, and able are you to change?
right now, on a scale of 1-10
1-not ready at all, 10-completely ready

How READY are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

How WILLING are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

How ABLE are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

Disclaimer

Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness consultation Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

Please type your name below.