New Client Intake

All information provided in this form will be kept strictly confidential and is submitted via a secure webpage.

This form will take between 10-20 minutes to fill out, depending on how much detail you put into the answers.
You will need a tape measure to measure hips and waist. Also, I will ask you for your resting heart rate. If you do not have time today to answer those questions, skip them for now. To measure resting heart rate, take pulse upon waking up (before sitting up or standing up). The alternative method is to lie down for 10 minutes and then take pulse.

Name*

Date of Birth*

Email*

Preferred Phone to call*

Can I text you at this number?
YesNo

Today’s Date

Address

City

Zip

Preferred Video call
Apple FaceTimeSkype (provide username)

Click on tab below to open

  • STEP 1: Goals and Objectives
  • STEP 2: Lifestyle Assessment
  • STEP 3: Physical Condition
  • STEP 4: Physical Activity Readiness Questionnaire (PAR Q)
  • STEP 5: Waiver & Policies

Consider activities you want to do but cannot or do not do right now, and how you want to feel. Please be specific. Consider what you want to be able to do within 3 months. You can list shorter and longer-term goals too.

  1. What is the most important change you want to make?
  2. What is the next most important change you want to make?
  3. What else would you like?
  4. How will your life be different when you achieve these goals (or even one of them)?
  5. What’s getting in your way? (What obstacles do you face?)
  6. What help you do you need?
  7. What do you LOVE to do? What activities in your life bring you the most joy? (even if you’re not doing them right now)
  8. Imagine it is one year from today, and you are living life in a way you love. Please write a thank you letter to yourself (from the future) describing how you feel and how you are living now. Please use as much detail as possible. Dream big and imagine the new you feeling your absolute best!

  1. How many servings of fruits and vegetables do you eat most days?

    (One serving is ½ cup cooked, 1 cup of leafy greens like lettuce/spinach, or to keep it simple, imagine size of 1 medium carrot)

  2. How many ounces or glasses of water do you drink on most days?
  3. How many of these beverages do you have each day?
      Soda:
      Coffee
      Tea:
      Herbal tea
      Milk:
      Juice
      Sports drinks
  4. How many of these beverages do you have per day or per week? Also you can answer per workday or per weekend day.
      Wine
      Beer
  5. How often do you eat in restaurants? (Estimate number of meals per week)
  6. Per week, how often do you eat in other people’s homes / or at parties?
  7. What time do you normally go to sleep?
  8. what time do you normally wake up?
  9. Please rate your ability for the following on a scale of 1-10 (10 is perfect).
      Fall asleep
      Stay asleep/Fall back asleep if you wake up in the night
      Manage stress
      Positive Self-Talk (What you say to yourself in your head)
      Digest food easily (without cramps, constipation or diarrhea)
      Have enough energy to do what matters
  10. What strategies do you use to manage stress?
  11. How many days per week do you get physical activity? Please tell me what you do.
  12. How physically active are you during your workday? Sit most of the dayMove around someI have a physically active job
  13. Please list the people who support you the most and want you to be your best.
  14. If you have children, please list names and ages.
  15. If you have pets, please list type of pet and names.
  16. Describe your career.
  17. Do you wear clothes and shoes to work that allow you to walk quickly and comfortably? Describe if needed.
  18. What else would you like me to know about you, your habits, your life, your world?

  1. Please mark location of any discomfort below. Consider discomfort level this week, give each location a number 1-10 and use the drop-down box to describe it. 1 is very low pain or discomfort, 10 is very, very high level of pain. Please provide any details you want me to know.
    • Neck
      Shoulders
      Upper Back
      Lower Back
      Hip
      Knee
      Ankle
      Foot
  2. Previous Injuries
  3. Previous Surgeries
  4. If there is a single most important physical issue to address, what is it and what caused it? Include specific event or stress.
  5. How long have you had the problem?
  6. List all medications and vitamins/supplements and the reason you take them.
  7. When was the last time you saw your doctor?
  8. Do you see any other health/wellness/medical practitioners? (acupuncture, massage, etc) Who else is on your health team?
  9. Can you get through a two-hour movie or meeting without leaving to relieve your bladder?
  10. Please describe any other health issues that you want me to know about.
  11. Today’s Waist Circumference: Measure smallest part of waist (or one inch above navel) – The important thing is that you measure the same place each time to see progress.
  12. Today’s Hip Circumference: Measure widest part of hips & buttocks.
  13. Divide Waist by Hips =
  14. Take pulse for one minute when you wake up, before sitting or standing up. Try to take it three separate days and average. OR – Lie very still for 10 minutes and take pulse, do three different days if possible and average numbers. Resting Heart Rate
  15. Today’s Height Feet Inches
  16. Today’s Weight
  17. Today’s sizes:
      Pants
      Dress
      Tops
  18. What other measurements are meaningful to you? Take them now or ask me to help you when we meet.
  19. At your first appointment with me, we will take photos in workout clothes. If it is meaningful for you to have other photos for your own comparison, take them today.

If you are between the ages of 15 and 69, the PAR Q will tell you if you should check with your doctor before you start an exercise program. If you are over 69 years of age, and you are not used to being very active, check with your doctor.


YES or NO
  • Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YesNo
  • Do you feel pain in your chest when you do physical activity? YesNo
  • In the past month, have you had chest pain when you were not doing physical activity? YesNo
  • Do you lose your balance because of dizziness or do you ever lose consciousness? YesNo
  • Do you have a bone or joint problem that could be made worse by a change in your physical activity? YesNo
  • Is your doctor currently prescribing drugs for your blood pressure or heart condition? YesNo
  • Do you know of any other reason why you should not do physical activity? YesNo
  • PAR Q: Adapted form ACSM’s Health/Fitness Facility Standards and Guidleines, 1997 by American College of Sports Medicine


If you answered YES to one or more questions, Talk to your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PARQ and which questions you answered YES. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

If you answered NO honestly to all PARQ questions, You can be reasonably sure that you can: Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.

Delay becoming much more active... If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better. If you are or may be pregnant – talk to your doctor before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness professional or doctor. Ask whether you should change your physical activity plan.

By accepting this document, I acknowledge that I have been informed of the need to obtain a physician’s examination and approval prior to beginning this wellness, nutrition, and exercise program. I fully understand that the program may be strenuous and choose to participate completely voluntarily. I accept all responsibility for my health and any resultant injury or mishap that may affect my wellbeing, or health in any way. I hold harmless of any responsibility, the instructor, facility or any persons involved with this program or testing procedures.

I understand that a fitness professional is not a medical doctor. Any chart or questionnaire does not replace the need for a medical exam and should not be used to defer seeking advice from a trained medical professional.

I understand that if I do not show up for my appointment, or if I cancel within 24 hours, I will be charged 100% of the fee.

I’ve read and accept this Terms & Conditions