Fitness Client Intake Form by aimeeleann August 2, 2022 Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Email *Age *Height *Weight *Date of Birth *Any Food Allergies or Sensitivities? (Please Explain) *Any Injuries or Medical Conditions? (Please Explain) *Are you currently undergoing Physical Therapy? If yes, please explain.Any Medications you are currently taking? (Please Explain) *Please list ALL supplements you are currently taking: *How many bowel times are you having bowel movements each day? *Occupation: *Work Activity Levels: *1) Sedentary2) Lightly Active3) Moderately Active4) Very Active5) Extra ActiveHow active are you in the following categories? Ex. (Duration/Times per Week):Stretching: *Walking: *Jogging: *Weight Lifting: *Body Measurements (Not Required):HipsWaistRight Upper ThighLeft Upper ThighYour favorite types of Physical Activity? *What is your biggest barrier to Exercise/Physical Activity? *What are your Short Term Fitness Goals? *What are your Long Term Fitness Goals? *Which of the following best describes you? *I can practically eat anything I want and I do not gain weight. It’s hard to gain weight.I can lose or gain weight by adjusting my activity level and eating habits.I find it difficult to lose weight easily and have to watch what I eat.None of theseAre you a binge eater? *YesNoHow much water do you drink a day? *On your most HEALTHY days... What do you eat in your current typical day? (Be specific / Include beverages) *On your most UNHEALTHY days... What do you eat in your current typical day? (Be specific / Include beverages) *Health and Medical Conditions *None ApplyAbnormal EKGHeadache/MigraineKnee ProblemsKidney DiseaseLeukemia or CancerLiver DiseaseLow Blood PressureOsteoporosisPancreatic DiseasePersistent FatigueRecently Broken BonesRheumatic FeverStomach ProblemsSwollen/Painful JointsAnemiaArthritisAsthmaBack ProblemsBursitisDiabetesEmphysemaHeart DiseaseHerniaHypertensionHypoglycemiaLactationsLung ProblemsStrokeNone ApplyOther (Fill out below)Check any health conditions that apply:Please list any other Health and Medical Conditions not mentioned above: *Medications *List ALL Supplements you are currently taking: *Foods you like (Check all that apply): *Albacore TunaBlack BeansAsparagus Chicken BreastBrown RiceBeets CodChiaBroccoli Cottage CheeseChick PeasBrussel Sprouts Eggs (whole)BuckwheatCauliflower Egg WhitesHempseedCherry Tomato Ground BisonHummusCucumber Ground BeefJasmine RiceGreen Beans HalibutQuaker OatsRed Peppers Plain Greek YogurtQuinoaSpinach SalmonRed PotatoesZucchini Sirloin SteakSoy BeansSpaghetti SquashTempehSweet PotatoYellow Squash CashewsMilkCabbageAlmondsApple Natural Almond ButterAvocado Peanut ButterBananasMixed NutsCantaloupe GrapefruitEdamame SpaghettiBlueberriesEzekiel 7 Sprouted GrainsEzekiel Bread-FlaxEzekiel Raisin BreadBlack Tea Rice CakesDecaf Coffee Regular CoffeeBlack Eyed PeasTea Energy DrinksStrawberriesOthers (Select to add more)Foods that you like continuedSubmit Share Email