Intake Form

Welcome! Please take a few minutes to complete this form so we can better understand your needs, preferences, and goals. Your answers help us create a personalized plan that supports your wellness journey.

Name

First Name

Last Name

Phone Number

(###)

###

####

DOB

YYYY

Occupation

What are your top 2-3 wellness goals?

Why are these goals important to you?

In the past, what has prevented you from reaching these goals?

Do you have any current or past injuries?

Do you have any diagnosed health conditions?

Are you currently taking any medications or supplements?

Describe your current exercise routine (if any).

What types of movement do you enjoy (e.g. strength training, yoga, walking)?

On a scale of 1-10, how confident do you feel in an gym setting?

What do you currently eat in a day (breakfast, lunch, dinner, snacks)?

How would you describe your overall eating habits?

Do you follow any specific dietary preferences (plant-based, gluten-free, etc.)?

How is your hunger throughout the day?

How much water do you drink daily?

How often do you consume alcohol?

How would you rate your average stress level?

What are your biggest sources of stress?

How many hours of sleep do you get each night?

How would you describe the quality of your sleep?

Is there anything else you'd like me to know to better support you?