Strong Mamas Fitness
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Client Intake Form
Basic Information
Name *
Email *
Phone Number *
Date of Birth *
Address *
City *
State *
Zip Code *
Best Method of Contact *
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Phone
Text
Email
Training Preference *
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Private Training
Buddy Training (up to 3 people)
Recorded Video Workouts
Training Type
Please select what training type you are interested in: *
Please select...
Prenatal
Postpartum
General
Please select a training type to continue with the rest of the form.
Physical Activity
Please describe your
pre-pregnancy
physical activity or exercise routine (# days/wk, intensity, exercise type, etc.)
Please describe your
pregnancy
physical activity or exercise routine (# days/wk, intensity, exercise type, etc.)
Do you currently participate in structured physical activity?
Yes
No
Cardio Minutes
Times per Week
Muscular Training Sessions/Week
Flexibility Sessions/Week
Sports Minutes/Week
List sports or activities you participate in
Do you engage in other forms of regular physical activity?
Yes
No
Have you experienced any injuries that may limit your physical activity?
Yes
No
Do you have any physical-activity restrictions?
What are your honest feelings about exercise/physical activity?
What are some of your favorite physical activities?
Medical Information
How would you describe your present state of health?
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Very well
Healthy
Unhealthy
Unwell
Other
List current medications (include prescriptions and over-the-counter)
Do you take a prenatal vitamin?
Yes
No
Do you take any vitamin, mineral, or herbal supplements?
Yes
No
Date of Test
Total Cholesterol
HDL
LDL
Triglycerides
Blood Sugar
When was the last time you visited your physician?
Cholesterol Information
Have you ever had your cholesterol checked?
Yes
No
Date of Test
Total Cholesterol
HDL
LDL
Triglycerides
Blood Sugar
Have you ever had your blood sugar checked?
Yes
No
Please check any conditions that apply to you:
Allergies
Amenorrhea
Anemia
Anxiety
Arthritis
Asthma
Celiac Disease
Chronic Sinus Condition
Constipation
Crohn's Disease
Depression
Diabetes
Diarrhea
Disordered Eating
GERD
High Blood Pressure
Hypoglycemia
Hypo/Hyperthyroidism
Insomnia
Intestinal Problems
Irritability
Irritable Bowel Syndrome (IBS)
Menopausal Symptoms
Osteoporosis
PMS
PCOS
Pregnant
Skin Problems
Ulcer
Major Surgeries
Past Injuries
Other Health Conditions
Prenatal
Medical
OB/GYN or Midwife's Name
Contact Info (for OB/GYN or Midwife)
# of Weeks Pregnant
Due Date
Are you having multiples?
Yes
No
How many?
Baby's gender (optional)
Pregnancy History
Have you ever been pregnant before? If so, how many times? Have you experienced any pregnancy loss?
Names/ages of any other children (if applicable)
Do you have any lingering issues from previous pregnancies (pain, incontinence, core issues, etc.)?
Pregnancy Experience
How are you feeling physically so far (nausea, fatigue, energy level, etc.)?
Do you have any pains or injuries that arose during pregnancy? If so, how long have you been experiencing them, and have you sought any diagnosis or treatment from a medical professional or physical therapist?
Did your doctor or medical provider give you any exercise guidance or restrictions? If so, what is the rationale?
Do you experience accidental urine leakage during sudden movements (coughing, laughing, sneezing) or during exercise? If so, do you know when this started and what activities it tends to occur with?
Do you have a vision for the type of delivery you would like to have (hospital vs. home birth, unmedicated, epidural, planned C-section, etc.)?
Do you feel supported and respected by your medical provider (doctor or midwife)?
Do you plan to take any classes or work with any other experts to prepare for labor and early postpartum (i.e. birthing classes, working with doula)?
Postpartum
# of weeks/months/years postpartum
Date gave birth
What pregnancy number is this for you?
Baby's (babies) name(s)?
Names/ages of other children (if applicable)
Pregnancy & Birth Experience
Describe how your most recent pregnancy experience felt physically - smooth, difficult, pains, injuries, complications, etc.
Where did you give birth?
What was your delivery type - vaginal, cesarean? If vaginal, were any tools used - forceps, vacuum? If cesarean, was it planned or emergency?
If you had a vaginal delivery, did you experience any vaginal tearing (1st, 2nd, 3rd or 4th degree) or other complications?
Describe your overall birth experience
Have you done any type of postpartum recovery work (physical therapy, acupuncture, massage, chiropractic, etc.)? Please give details.
Postpartum Experience
Have you experienced any urine leakage during activity, coughing or sneezing? Please give details.
Have you been checked for pelvic organ prolapse? If so, what was the diagnosis?
Have you been checked for diastasis recti (abdominal separation)? If so, what was the diagnosis?
At your postpartum checkup, what guidance did your provider give about returning to exercise?
How are you currently feeling physically?
Are you nursing or pumping? If so, how is that going?
Nutrition
What are your dietary goals?
Have you ever followed a modified diet?
Yes
No
Are you currently following a specialized eating plan?
Yes
No
Why did you choose this eating plan?
Was the eating plan prescribed by a physician?
Yes
No
How long have you been on the eating plan?
What are the major issues with your nutritional choices or eating plan?
How many glasses of water do you drink per day?
What else do you drink?
Lifestyle
How are you feeling mentally?
What is your support system like (spouse, partner, family, friends, support group, etc.)?
Do you have any favorite hobbies or activities you like to do?
Occupational
Do you work?
Yes
No
Are you on maternity leave?
Yes
No
When do you plan to return (if at all)?
Occupation
Describe your activity level during the work day
Sleep and Stress
How many hours of sleep do you get at night?
Rate your average stress level (1 = no stress, 10 = constant stress)
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1
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5
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7
8
9
10
What is most stressful to you?
Substance-related Habits
Do you drink alcohol?
Yes
No
Times per week
Average amount
Do you drink caffeinated beverages?
Yes
No
Average number per day
Do you use tobacco?
Yes
No
Goals
How likely are you to adopt a healthier lifestyle? (1 = very unlikely, 10 = very likely)
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1
2
3
4
5
6
7
8
9
10
What are your specific goals? Please list them in order of importance.
Do you have a desired timeframe for achieving these goals?
Do you have a weight-loss goal?
Yes
No
Why do you want to lose weight?
How many days per week can you commit to personal training?
Outside of training days, can you commit to doing other physical activity (e.g. walking, elliptical, yoga)? If so, what types of cardio activities do you enjoy doing?
Is there anything you'd like me to know as a coach? (i.e. what motivates you? what doesn't?)
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