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New Client Information Form

Basic Information

Name *

Email *

Phone Number *

Date of Birth *

Address *

City *

State *

Zip Code *

Best Method of Contact *

Phone

Text

Training Preference *

Private Training

Buddy Training (up to 3 people)

Recorded Video Workouts

Returning client?

Yes

If you feel your life has changed significantly enough to re-enter all fields of the intake form, please check this checkbox. Otherwise you will be instructed to fill out the portions pertaining to your training type selected in the next section.

Training Type

Please select what training type you are interested in: *

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, including cardio, strength training, fitness classes, and sports?

Yes

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

Have you experienced any injuries that may limit your physical activity?

Yes

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?

Very well

Healthy

Unhealthy

Unwell

Other

List current medications (include prescriptions and over-the-counter)

Do you take a prenatal vitamin?

Yes

Do you take any vitamin, mineral, or herbal supplements?

Yes

When was the last time you visited your physician?

Cholesterol Information

Have you ever had your cholesterol checked?

Yes

Check if unsure of results

Date of Test

Total Cholesterol

HDL

LDL

Triglycerides

Blood Sugar

Have you ever had your blood sugar checked?

Yes

Check if unsure of results

Date of Test

Test Results

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

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

Are you currently following a specialized eating plan, e.g. low sodium, keto, low carb, etc.?

Yes

Why did you choose this eating plan?

Was the eating plan prescribed by a physician?

Yes

How long have you been on the eating plan?

What are the major issues with your nutritional choices or eating plan, if any?

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

Are you on maternity leave?

Yes

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)

What is most stressful to you?

Substance-related Habits

Do you drink alcohol?

Yes

Times per week

Average amount

Do you drink caffeinated beverages?

Yes

Average number per day

Do you use tobacco?

Yes

Goals

How likely are you to adopt a healthier lifestyle? (1 = very unlikely, 10 = very likely)

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

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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