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Client Intake Form

Homepage Client Intake Form

Client Information

First Name *

Last Name *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Occupation

Occupation *

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How many days/week do you work *

How many hours/day do you work *

Does your occupation require you to travel often? *

Contact Information

Email Address *

Phone Number *

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Do you give PF4U Coaches permission to CALL or TEXT the phone number provided above? *YesNo

How did you hear about #PF4U

Health Information

Age *

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Height *

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Weight *

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Body Fat Percentage (if known)

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Do you own a smart watch? If so, what kind of watch?0 / 60

How active/sedentary will your typical day be on a scale from 1-10 (1-sedentary, 10- highly active)? *12345678910

Are you within 5 days of your last period? *YesNoUnsureN/A

Are you pregnant

Are you breastfeeding?

Do you suffer from any chronic medical conditions?

Do you take any medications, either prescription or non-prescription, on a regular basis? *Please list condition(s) and medications0 / 180

Do you smoke?

How many times per day?0 / 180

Do you drink alcohol?

How many drinks per week (on average)?0 / 180

How many hours of sleep do you receive PER night (on average)? *

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What are your favorite activities/hobbies? *

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On a scale of 1-5, how do you rate your health as a priority *12345(1=worst, 5=best)

On a scale of 1-5, how does your support system rate your health as a priority in their lives *12345(1=worst, 5=best)

Training Information

On a scale of 1-10, how would you rate your current fitness level? *12345678910(1=worst, 10=best)

How often do you take part in physical exercise? *

Number of times/week and how long/session.0 / 180

What kinds of activity do you currently complete? *0 / 180

How often would you REALISTICALLY like to exercise during your program? *

A.) Number of times per week? B.) Time (minutes) per session?0 / 180

Do you currently have or plan on obtaining a gym membership while participating in your Perfectfit4u program? *YesNo

Gym membership?If you answered YES to the previous question, what GYM do you have a MEMBERSHIP too?

Do you prefer to execute ALL of your workouts at the home? *YesNo

Do you prefer to execute SOME of your workouts at home and SOME of your workouts at the gym?a. How many days at home? b. How many days at the gym?

Do you have any equipment available at home?0 / 180

Please list, in order of priority, the TRAINING goals you would like to achieve through this program.

Nutrition Information

On a scale from 1-5, how would you rate your CURRENT nutrition/eating habits? *12345(1=Poor, 5=Excellent)

Do you have any food ALLERGIES? *YesNo (Ex. Celiac, Lactose Intolerance, etc.)

Please explain below0 / 180

Please let us know by checking the box of the food you may have taste aversions too:Chicken BreastTurkey BreastEggsEgg WhitesCodShrimpCanned TunaHalibutSalmonBeefYogurtCottage CheeseProtein PowdersProtein BarsOatsCream of WheatCerealRice CakesCrackersRiceQuinoaCouscousMilletSweet PotatoWhite PotatoPastaBreadBeansBerriesBananaPineappleMelonSeedsNutsNut ButterAvocadoCream CheeseOlive OilCocanut Oil

What are some of your favourite or most highly consumed foods on a daily basis? *

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How many times throughout the day do you currently eat (on average)? *

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Please describe your daily eating schedule/routine.

Do you tend to skip meals despite being hungry? *YesNoSometimes

Do you eat breakfast religiously? *YesNo

Do you tend to eat late at night? *YesNo

Do you have a preferred dieting method that has been proven to work for you in the past? *If so, please explain (Ex. Paleo, Vegan, Vegetarian, etc.) Feel free to explain further if needed. 0 / 180

Have you ever tracked your food intake? *YesNo(i.e. food diary)

How familiar are you with "macros" and "macro counting"? *12345(1=Poor, 5=Excellent)

Do you do your own grocery shopping? *YesNo

How important is it for you to be able to cook meals for your family members? *12345(1=not very, 5=every meal)

What appliances do you have at your disposal for food preparation on a typical weekday? *

(i.e. Stove, Oven, Toaster, Blender, Microwave, etc.)0 / 180

How many liters of water do you consume daily? (on average) *

0 / 180

Are you currently taking specific vitamins or any other supplements? *YesNo

Please include them here:

Please list, in order of priority, the NUTRITION goals you would like to achieve through this program.

Miscellaneous

Describe your ideal coach or what exactly you'd expect from an ideal coach *

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Would you like a membership to the Perfectfit4u App which includes a PRO membership that allows clients to track their food intake and body metrics/progress as well as receive access to workout demo videos of their programs. Login information will be provided with your first program. *YesNo(for iPhone or Android) for $3.99/month?

Please list anything that you may feel is a concern or information that has not been disclosed that you feel our staff should know in order to develop the program best suited for you.0 / 180

Start Photos

Do you have your start photos ready for upload? If so, upload them below. If not, please email front, back and side profile photos to info@perfectfit4u.ca

Front

No file chosen

Back

No file chosen

Side

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PARQ

Physical Activity Readiness Questionnaire

Has your doctor ever said that you have a heart condition or high blood pressure? *YesNo

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity? *YesNo

Do you lose balance because of dizziness or have you lost consciousness in the last 12 years? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *YesNo

Have you ever been diagnosed with another chronic medical condition? *

Please describe:

Are you currently taking prescribed medication for a chronic medical condition?

Please describe:

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. *YesNo

Has your doctor ever said that your should only do medically supervised physical activity? *YesNo

Date

Please select today's date.

By checking this box, your are eSigning this form.I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed, and become invalid if my condition changes. I also acknowledge that #Perfectfit4u may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.