Client Intake Form

Full Name: Email Address: Age: Sex: Height (inches): Weight (lbs):

Dietary Preferences (check all that apply):

Vegetarian

Vegan

Ketogenic

Paleo

Mediterranean

Low Carb

Food Allergies/Intolerances:

Current Activity Level: Fitness Goals (check all that apply):

Weight Loss

Weight Gain

Muscle Building

Improve Endurance

Increase Flexibility

General Health

Exercise Preferences (check all that apply):

Gym Workouts

Home Workouts

Walking/Hiking

Swimming

Yoga/Pilates

Cycling

Physical Limitations/Injuries:

Medical Conditions/Medications: