Full Assessment Intake Form

Date of birth

Preferred Method of Communication?*

Do you have any pre-existing medical conditions? (E.g. diabetes, hypertension, Crohn's Disease, Heart Disease, etc.)*

Are you currently taking any medications? *

Have you ever had surgery or any serious injury?*

Do you any joint or muscle pain/injuries*

Do you have any physical limitations or disabilities that may affect your ability to exercise?*

Do you have any physical limitations or disabilities that may affect your ability to exercise?*

Are you pregnant or trying to become pregnant?*

How do you describe your current activity level?*

Do you currently exercise?*

Do you have any sedentary habits (e.g. desk job, long periods of sitting)?*

How many hours of sleep do you get per night?*

How would you rate your current stress level?*

How many meals/snacks do you typically eat a day?*

Do you smoke, drink alcohol, or use recreational drugs?*

What are your primary fitness goals? (Check all that apply)*

How much weight do you want to lose?

How soon do you want to achieve your fitness goal?*

Do you smoke or use tobacco products?*

Have you tried to lose weight in the past?*

Do you have a specific event or milestone you're working toward (e.g., wedding, vacation, competition)?*

Are you currently following a specific diet plan?*

How would you describe your eating habits?

How often do you eat out or order takeout?

Do you have any dietary restrictions or allergies?

Do you track your food intake or calories

How much water do you drink daily?

How much water do you drink daily?

How many days a week are you available to work out?

Preferred workout times:

What type of workouts do you enjoy? (Check all the apply

Do you prefer working out alone or in a group setting?

Are there any specific exercises or activities you dislike?*