Client Intake

Can’t wait to get to know you!

New Client Intake Form

Step 1 of 8 – Contact Info

12%

Name(Required)







MM slash DD slash YYYY


Preferred Method of Contact(Required)





In general, what do you want out of this experience? What are your goals? (check all that apply)(Required)

























1 – Horrible 2 3 – Okay 4 5 – Amazing

Are you regularly active? (moving more than sitting)(Required)






Who lives with you? Check all that apply.(Required)











Who does most of the grocery shopping? Check all that apply.(Required)











Who does most of the cooking in your household? Check all that apply.(Required)











Who decides the menu/meals for the week? Check all that apply.(Required)











1- not very supported 2 3 4 5- I have a wonderful support system

What is your typical stress level on an average day?(Required)











On average, how many hours of sleep do you get per night?(Required)













No I think so Neutral Yes, I’m ready

No I think so Neutral Yes, I’m ready

No I think so Neutral Yes, I’m ready


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