CLIENT INFORMATION:
First Name
Last Name
DOB
Phone Number
E-Mail Address
Emergency Contact:
Phone Number:
GOALS
Please list any/all concerns about your health, eating habits, fitness, and/or body, rating them in matters of importance.
Please explain why the top 3 are the most important.
What do you expect from your coach?
CHANGE
If so, what? (please specify which ones worked well for you)
How specifically would you like this to be different?
If you were to consider making changes to these habits, health choices and your body, what might come to mind?
Until now, what has been the biggest barrier to making these changes?
What does your fitness program consist of currently?
ENVIRONMENT
If you have children, please list the number and ages.
How many hours per week would you say you spend on the following:
Activity
Hours per Week
Unpaid Work (housework, errands)
How do you normally cope with your stress?
Please list any injuries, surgeries, or illnesses that you have had in the past.
Surgery/Illness/Injury
Date
Years
Please list any medications and/or supplements that you are currently taking.
Medication
Reason
Disclaimer Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
Client Signature:
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