Client Intake and Assessment Form

Please complete the following form. Please note that the form does not autosave; it will not be submitted until you click Submit at the bottom of the form.

Full Name
Do you currently have or have you ever been diagnosed with any cardiovascular metabolic respiratory or other medical condition that affects exercise participation
If no, type NA
Medical History (Select all that apply)
Please describe any other considerable medical history that is relevant.
Type NA if not applicable.
Do you have any exercise restrictions
If none, type NA
Do you deal with chronic pain?
Have you worked with a coach before
Do you track food intake
Do you have a history of restrictive dieting?
Recent weight change
If known. If not, leave blank. Estimations are fine.
If known. If not, leave blank. Estimations are fine.
If known. If not, leave blank. Estimations are fine.
Please describe your stress levels over the last 2-4 weeks.
Type N/A if not applicable.
I confirm the information above is accurate and understand exercise involves inherent risk.