Client Intake Sheet

All the information you provide is strictly confidential and is for the sole purpose of servicing the client, their program, their progress, and well-being. This information will not be shared with parties outside of Straight to Fit.

Today's Date:

First Name

Last Name

Date of Birth

Address

Address Line 1

Address Line 2

City

Province / State

Postal Code

Country

Phone / Mobile

Health

Please rate how important your health is to you.

1 - Not Important

2 - Slightly Important

3 - Moderately Important

4 - Important

5 - Very Important

How stressful do you rate your occupation?

1 - Not Stressful

2 - Slightly Stressful

3 - Moderately Stressful

4 - Stressful

5 - Very Stressful

How many hours of sleep do you get each night?

What time do you usually go to bed?

Are you taking any medications? (if YES, please list)

Are you taking any supplements? (if YES, please list)

Do you suffer from any of the following (select all that apply)

Anxiety

Arthritis

Asthma

Back Pain

Bowel Disorders

Depression

Diarrhea

Diabetes

Dizziness

Eating Disorders

Epilepsy

Fainting

Heart Condition

High Blood Pressure

High Cholesterol

Indigestion

Low Blood Pressure

Ulcer

Headaches

Do you have any allergies? (if YES, please list)

Have you had any surgeries? (if YES, please list)

What post surgery rehab did you do?

Have you had any sprains, broken bones, or dislocations? (if YES, please list)

What post injury rehab did you do?

Are there any therapies, treatments, programs, or healers you are currently involved with? i.e. Chiropractor (if YES, please list)

Do you have any regular physical discomfort or pain? Please describe.

Do you smoke / vape?

Yes

How many daily?

What method of weight loss have you tried in the past? (please list)

What was your preferred method, and why?

When did you last see a doctor for a physical?

How would you describe your gender?

Female

Male

Females Only

Are you pregnant?

Yes

Have you recently experienced any changes in your menstrual cycle?

Yes

Do you consider yourself to be in menopause?

Yes

What symptoms do you experience?

Physical Activity and Exercise

Do you think there is anything you personally should do to improve your health?

Yes

Circle each item you think is important to improve.

Exercise More

Reduce Medications

Improve Posture

Improve Eating Habits

Increase Energy Levels

Lose Weight

Gain Weight

Reduce Stress Levels

Increase Strength

Burn Fat

Flexibility

Core Strength

Other

Other (please specify)

Physical activity is any movement of the body produced by the skeletal
muscles, while exercise is physical activity that is planned and repeated for
the purpose of improving health and fitness.

How long have you exercised or played sports regularly?

I do not exercise regularly

Less than 1 year

1 to 2 years

2 to 5 years

5 to 10 years

More than 10 years

How much physical work is required at your job?

Are there any tasks in your job / daily activities that cause you physical discomfort? (please list)

Outside of your daily work or responsibilities, how often do you participate in moderate to intense exercise? (defined as activity which increases your heart rate for at least 20 minutes through such activities as brisk walking, cycling, jogging, stair climbing, etc.).

Seldom or never

1-2 times a week

3-4 times a week

5+ times a week

What are your 3 most important personal fitness goals?

Lifestyle

Do you drink tea or coffee? How much daily?

How often do you go grocery shopping?

How many times a week do you serve packaged or prepared foods?

What types of prepared foods do you serve?

How many times in a month do you eat out?

How much water do you drink daily?

Do you drink alcohol? How much and how often?

Please indicate any additional information that you consider important in the design of a fitness program for you, including your specific goals.