Coach Donovan’s Intake Form for New Clients

Contact Info

Name*

First Last

Age*

Email*

Phone*

Your Main Goals

Why are you reaching out to a health coach and personal trainer today? What specific health, fitness, wellness, and lifestyle changes would you like to make?

Most Important Goal*

Second Most Important Goal

Third Most Important Goal

How would your life be different if you were to achieve these health and fitness changes?*

How do you feel a personal trainer & health coach will help you achieve your goals?*

Describe the patterns you seem to fall into again and again with regard to making health, lifestyle, and fitness transformations. What other diets, programs, or approaches have you tried in the past, and what were your results?*

Describe your beliefs about your ability to transform your own health.*

What support do you have at home, at work, and in your life to succeed in this program?*

What barriers can you perceive or predict? What aspects of your home, work, and life have previously detracted from your ability to succeed?*

What hobbies, interests, and passions do you partake in?*

Please share any information you feel is pertinent with regard to your level of commitment through this process. What is going to motivate you to keep going even when it gets a little uncomfortable?*

Nutrition

DIET SNAPSHOP. Generally, how would you describe your current diet? Provide a basic snapshot of what an average day looks like: Breakfast, lunch, dinner, snacks, treat and beverages. Please include times of day as well.*

PROTEIN. Which protein sources do you eat? How often do you eat them?*

WHOLE GRAINS. What types of whole grains do you eat? How often do you consume them?*

REFINED CARBOHYDRATES. What types of refined carbohydrate snacks (like candies, crackers, cookies, pastries, baked goods) do you eat? How often do you eat them?*

What are your favorite foods?*

Do you try to avoid any certain types of foods?*

What foods do you crave? How often do you give in to the cravings?

Do you experience any symptoms/feelings/behaviors if meals are missed? Explain.*

Are you currently taking any nutritional supplements? List all.*

How many glasses or servings of WATER do you have in a day, week, or month?*

Quantity

Frequency

How many glasses or servings of COFFEE do you have in a day, week, or month?*

Quantity

Frequency

How do you take your coffee?

How many glasses or servings of TEA do you have in a day, week, or month?*

Quantity

Frequency

How do you take your tea?

How many glasses or servings of FRUIT AND/OR VEGETABLE JUICE do you have in a day, week, or month?*

Quantity

Frequency

Please provide details around your consumption of juices: type, when, why?

How many glasses or servings of DAIRY MILK do you have in a day, week, or month?*

Quantity

Frequency

How many glasses or servings of NON-DAIRY MILK do you have in a day, week, or month?*

Quantity

Frequency

Please provide details around your dairy and non-dairy milk usage: type, when, why.

How many glasses or servings of SMOOTHIES AND SHAKES do you have in a day, week, or month?*

Quantity

Frequency

Please provide details: smoothie/shake ingredients; when and why you consume smoothies or shakes, etc.

How many glasses or servings of SODA do you have in a day, week, or month?*

Quantity

Frequency

How many glasses or servings of DIET SODA do you have in a day, week, or month?*

Quantity

Frequency

How many glasses or servings of ALCOHOL do you have in a day, week, or month?*

Quantity

Frequency

Please provide details: What type of alcoholic drink, when, why?

Energy & Stress

Describe your energy levels throughout the day. Do you have highs and lows? When?*

On a scale of 1 to 10, how would you rate your stress level?*

Describe your sources of stress.*

How do you react to stress? Do you rely on any coping mechanisms?*

Sleep

SLEEP QUALITY. Check all that apply (use CTRL to select multiple):*

Sleep quantity. How many hours of sleep do you get most nights?*

What time do you typically go to bed?*

What time do you typically wake up?*

What else should your coach know about your sleep habits, patterns, quantity, and quality?

Exercise

Please describe your daily NON-EXERCISE MOVEMENT. This can include things like the walking you do throughout your day, moving around, chores, manual/physical tasks, fidgeting, etc.*

What do you do for EXERCISE? Exercise is described as the deliberate attempts you make to move your body; your workouts, weight lifting sessions, yoga or fitness classes, and taking long walks. Describe the types of activities, frequency, duration, intensity, etc.*

Are you a competitive athelete?*

If so, describe your sport.

What are your fitness goals? Check all that apply (use CTRL to select multiple):*

If you have other fitness or specific performance goals, describe them here.

Do you have any physical limitations in terms of your ability to partake in an exercise program? Include any old injuries that still interfere with your ability to exercise.*

Have you ever worked with a personal trainer before?*

If you have worked with a trainer before, what was your experience and results? Why did you discontinue?

Bowel Health

How often do you have a bowel movement?

Do you ever have difficult or unusual bowel movements? If so, describe.

Work and LIfe

What do you do for work?*

Do you usually enjoy your work?*

How many hours a day do you work?*

What type of schedule do you work? Check all that apply (use CTRL to select multiple):*

If you answered 'random schedule,' briefly explain what that means.

What is your family and home-life situation? Married? Children? Taking care of elderly parents? Please describe with as much detail as you feel comfortable sharing.*

Medical History

CURRENT HEALTH CONDITIONS. Have you been diagnosed with any diseases, and/or are you on any prescribed medications?*

Have you ever been hospitalized, had any major surgery? Please describe.*

Do you have any allergies or sensitivities?*

If Yes, please describe.

Do you smoke?*

Do you partake in recreational drugs?*

If Yes, which ones, how often, and why?

Describe any pertinent family medical history.

FEMALES: Are you or could you be pregnant?

FEMALES: Are you peri-menopausal, menopausal or experiencing menopause symptoms? Describe.

Conclusion & Acknowledgement

Do you have any additional notes, comments or questions?

INTAKE FORM

READY TO TAKE YOUR FIRST STEP TOWARDS HEALTH AND FITNESS?

Contact Info

Your Main Goals

Nutrition

Energy & Stress

Sleep

Exercise

Bowel Health

Work and LIfe

Medical History

Conclusion & Acknowledgement

INTAKE FORM

BUILD A HEALTHY, STRONG BODY

FEEL AMAZING EVERY SINGLE DAY

OVERCOME YOUR LIMITATIONS

READY TO TAKE YOUR FIRST STEP TOWARDS HEALTH AND FITNESS?

Contact Info

Your Main Goals

Nutrition

Energy & Stress

Sleep

Exercise

Bowel Health

Work and LIfe

Medical History

Conclusion & Acknowledgement