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Intake Form

First Name *

Last Name *

Birth Date

My Gender

My Gender

Weight

Height

Phone *

Email *

Do you have any injuries? If yes, please list below.*

How does your current diet look like?*

Low-fat

High Protein

Low Curb

Vegetarian/vegan

No Special Diet

Other

What is your daily activity level?*

1 (Low)

2

3

4

5 (High)

What is your daily stress level?*

1 (Low)

2

3

4

5 (High)

How often are you willing to dedicate time to yourself?*

Once a week

Twice a week

Three times a week

4 times a week

5 times a week or more

How long do you want your session to last?*

30 minutes

1 Hour

1.5 Hours

What training style would you prefer? *

Online/ Virtual

1:1 Training

Group training

Which of the following statements fit in with your goals the most?*

Improve Overall Health

Increase Strength

Weight Loss/Fat Loss

Maintain

Improved endurance

Increase muscle mass

Weight Gain

Are you willing to put in the work? *

1 - Nope

2 - Maybe

3 - I'm trying to

4 - Yeah, I guess so.

5 - Heck yea! Let's GO!

What else would you like to share with us:

How committed are you to investing in yourself at the level needed to achieve your goals?

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