FITNESS INTAKE | MR LNE Motivation and Consulting |

Fitness Training Intake Form

First name

Last name

Email

Phone

Company Name

Emergency Contact Name

Emergency Contact Phone:

Your Relationship to this Emergency Contact:

Health & Medical History: Have you ever been diagnosed with any of the following?

Other diagnoses: please specify.

Are you currently taking any medications?

Yes

No

If yes to taking medications, please list here. If not, answer NA.

Do you smoke or use tobacco products?

Are you currently pregnant or recently postpartum?

Yes

No

Not Applicable

Lifestyle & Activity Level AT HOME

Sedentary

Light

Moderate

Active

Any Current Exercise Routine (type, frequency, duration):

So, how would you rate your current fitness level?

Beginner

Immediate

Advance

Average hours of sleep per night:

Average time of REST, BREAKS, and MOMENTS OF PEACE throughout your day? (none, 30 minutes, 1 hour,...)

Describe your nutrition habits:

Poor

Fair

Good

Excellence

Any other target areas?

How many days per week can you commit to training?

Signature

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