INITIAL INTAKE FORM

We’re here to create a customized program based on your unique values, experiences and habits. This form is the first step in that process. To help us create the best program for you, please answer these questions as openly and honestly as possible. There is no judgment here – answering these questions will only help you overcome barriers and reach your health and fitness goals. 

Name *
Name
Address *
Address
Phone *
Phone
Have you had unintentional weight loss/gain of 10lbs or more in the last 3 months?
Check all that apply
Exercise Habits
Activity Level
Select your current level of work or lifestyle
Exercise Level
Select your current level of exercise
Exercise frequency and schedule
Please include all
Nutrition Habits
Eating Habits
Check all that apply
Food restrictions
Check all that apply
A serving is approximately equivalent to the size of a small apple or a handful of berries.
A serving is approximately equivalent to 1 cupped handful of broccoli or 2 cups of leafy greens.
A serving is approximately equivalent to 1 cupped handful of rice or oats or single piece of bread.
A serving is approximately equivalent to 1 cupped handful.
A servings is approximately equivalent to a fist size portion of yogurt, a small glass of milk or 4 stacked dice of cheese.
A serving of eggs is 2 eggs
A serving is approximately 1 fist size.
Single servings of chips, cookies, crackers, etc.
Eating frequency
Check all that apply
Stimulant Habits
Coffee, tea, soda, energy drinks
Stress Level
Please rate the following
Please rate the following
I have a high level of stress in my work life.
I have a high level of stress in my personal life.
My stress is mostly physical stress.
My stress is mostly emotional stress.
Sleep Habits
Do you suffer from insomnia/sleep disorder?
Do you often abruptly awake from sleep?
Do you suffer from depression or mood swings?
Goals
Energy & Vitality- I'd like to:
Check all that apply
Longevity & Life Enrichment
Check all that apply
Body composition/Fat/Muscle
Check all that apply
Stress Reduction- I'd like to:
Check all that apply