Client Intake Form

GENERAL INFORMATION:
Name *
Name
Street, City, Province/State
Please leave the best number we can reach you at.
Personal Information
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
(This is aside from the gym) Sedentary, Lightly Active, Active, Very Active? 1 being sedentary and 10 being very active. Sedentary meaning: spend most of your day sitting (Ex. desk job) Lightly Active meaning: Spend a good part of your day on your feet (Ex. Like a teacher, or a hairdresser, etc.) Active meaning: Spend a good part of the day doing physical activity (like a waitress or mailman) Very Active meaning: You are doing physical activity for the majority of the day (like a carpenter, or landscaper, tradesman, oilfield worker, etc.)
HOW did you hear about #Perfectfit4u? *
Please check which answer applies to you.
Health ~ PAR-Q Form
Please answer YES or NO to the following questions, unless otherwise stated:
Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
Please list condition(s) and medications below:
Lifestyle Related
Please answer YES or No to the following questions, unless otherwise stated:
(1 being desk job/sedentary and 5 being EXTREMELY active/labor)
(1=low, 10=high)
Do you regularly use the services of:
Please check those that apply
Developing Your Fitness Program
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)
If so, WHAT gym?
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.)
If YES, how many times per week could you devote to the gym? And how many days could you devote to home workouts?
Describe your ideal coach or what exactly you'd expect from an ideal coach.
Goal Setting
(1=Unhealthy, 3=Average, 5=Good)
Nutrition Information
Please answer YES or NO to the following questions, unless otherwise stated:
(1=Poor, 5=Excellent)
(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.
(Bulimia, Anorexia, BED, etc.)
(1=Poor, 5=Excellent)
(1=not very, 5=every meal)
(i.e. Stove, Oven, Toaster, Blender, Microwave, etc.)
(Bored, Social, Stressed, Tired, Depressed, Happy, Nervous)
Which do you prefer? *
Please choose ONE option below:
Miscellaneous
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.”