Client Intake Form

GENERAL CLIENT INFORMATION:
Name *
Name
Street, City, Province/State
Please leave the best number we can reach you at.
Feet and inches.
IF KNOWN Please provide the following Measurements: Hip:(Measured at widest circumference, be sure minimal clothing is worn and glutes are relaxed) Waist: (Narrowest point, just above the belly button, below lowest rib) Neck: (Narrowest part of the neck- under the adams apple area)
IF KNOWN
If applicable.
(1 being desk job/sedentary and 10 being EXTREMELY active/labor)
(1 being desk EXTREMELY sedentary (sitting all day/no exercise) and 10 being EXTREMELY active (moving all day/daily exercise)
HOW did you hear about #Perfectfit4u? *
Please check which answer applies to you.
LIFESTYLE INFORMATION
Please answer YES or No to the following questions, unless otherwise stated:
Do you regularly use the services of:
Please check those that apply
(1=low, 10=high)
MEDICAL INFORMATION
Please complete the following medical questions in full detail.
(Within the last five years)
Please list condition(s) and medications below:
NUTRITION INFORMATION
(1=Unhealthy, 3=Average, 5=Good)
(1=Poor, 5=Excellent)
(i.e. Breakfast, Snack, Lunch, Dinner, Snack)
(Bored, Social, Stressed, Tired, Depressed, Happy, Nervous)
(Keep in mind that two standard water bottles or four glasses of water equals one litre)
(i.e. food diary, My Fitness Pal)
(1=Poor, 5=Excellent)
(Bulimia, Anorexia, BED, etc.)
(Ex. Celiac, Lactose Intolerance, etc.)
Do you have any foods that you refuse to eat due to taste aversion? *
Please CHECK any foods you REFUSE to eat from the list below.
(Ex. Paleo, Vegan, Vegetarian, etc.) Feel free to explain further if needed.
(1=not very, 5=every meal)
(i.e. Stove, Oven, Toaster, Blender, Microwave, etc.)
Which do you prefer? *
Please choose ONE option below:
HEALTH - PAR-Q FORM
Please answer YES or NO to the following questions, unless otherwise stated. If you mark YES to any of the following Par-Q questions you will need to provide us with a doctors note before receiving your Training Program.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose balance because of dizziness or do you ever lose consciousness? *
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program? *
Do you know of any other reason why you should not do physical activity? *
If you marked YES to any of the above Par-Q questions you will need to provide us with a doctors note before receiving your Training Program.
DEVELOPING YOUR FITNESS PROGRAM
(1=worst, 10=best)
Per week and duration
What activities are you CURRENTLY involved in? *
Please check off those that apply.
Times per week
(ex. 30 min, 45 min, 1 hour, 1.5 hour)
(Morning, Afternoon, Night)
(ex. Fit4Less, Golds, Lethbridge Fitness)
If YES, how many times per week could you devote to the gym? And how many days could you devote to home workouts?
If so, please provide PHOTOS and a LIST of the equipment that you have at your disposal (if any) (Ex. Cardio machines, Resistance Bands, Bowflex, Dumbbells, Barbells, Skip Rope, etc.)
Describe your ideal coach or what exactly you'd expect from an ideal coach.
ADDITIONAL INFORMATION
Would you like a membership to the Perfectfit4u App (for IPhone and Android) for $3.99/month? *
PRO membership allows clients to track their food intake and body metrics/progress as well as receive access to workout demo videos of their programs. *Login information will be provided with your first program.
*If at any point you would like to cancel your subscription to the App, we do require 30 days’ notice. One more payment will follow and then your subscription will end.


“What you are to be, you are now becoming.”