Client Intake Form This is our starting point! This information will help your coach design your customized program. New client information. Personal Contact InformationName(Required) First Last Phone(Required)Who is your PF4U Coach?Pick A CoachCurrently do not have a PF4U coachI am part of the Transformation ChallengeSydneyKirstenAshlynDo you give permission to your PF4U Coach(es) to call or text you? Y/N(Required) Yes No Email(Required) This is where our coaches will be sending your programming! Please double-check your spelling! Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about PF4U?(Required)InstagramFacebookWeb SearchWord of Mouth ReferralOne of the PF4U CoachesOtherIf you were referred, please tell us from who! We would love to thank them but will not include your personal information. If a specific coach has referred you, please include their name here. Personal Health InformationAge(Required)Please enter a number from 12 to 99.Height(Required) In feet and inchesCurrent Weight(Required)Please enter a number from 75 to 999.In poundsBody Fat PercentagePlease enter a number from 1 to 100.Only include if results are representative of your current physique. If are unsure of this value and within driving distance to our headquarters- consider trying our Body Composition Machine! Do you own a smart watch? If so, what kind?If you do own a smart watch, what is your estimated calorie burn? This is your daily MOVE amount on an Apple Watch or Daily Calorie Burn on FitBitAre you within 5 days of your last menstrual period?(Required)YesNoN/AAre you pregnant?(Required)YesNoAre you breastfeeding?(Required)YesNoDo you smoke?(Required)YesNoDo you drink alcohol regularly?(Required)YesNoIf so, how frequently? Have you been diagnosed with any chronic medical conditions?If so, please explain.Have you been prescribed any medications which you are to take on a regular basis?If so, please explain.How many hours of sleep do you receive PER night on average?(Required)Please enter a number from 1 to 23.What are your favourite activities/hobbies?(Required)On a scale of 1-5, how do you rate your health as a priority?(Required) 1 2 3 4 5 1= low priority, 5= top priorityOn a scale of 1-5, how does your support system rate their health as a priority?(Required) 1 2 3 4 5 1= low priority, 5= top priorityWhat is your current occupation?(Required) How many days/week do you typically work?(Required)Please enter a number from 1 to 7.How many hours/week do you typically work?(Required)Please enter a number from 1 to 99.Does your occupation require you to travel often?(Required)YesNoTraining InformationHow frequently do you take part in physical exercise?(Required) Number of times/week and length/sessionWhat types of physical exercise do you currently complete?(Required)These are the types of exercise you are partaking in right nowWhat types of physical exercise have you enjoyed over your lifetime?(Required)These are the types of physical activities you have completed in the past, even if you are not currently involved. Do you have any chronic or acute injuries that your coach should be aware of while designing your exercise regime?(Required)Are there any specific movements or movement patterns that aggravate any pre-existing injuries you may have?(Required)On a scale of 1-5, how do you rate your current fitness level?(Required) 1 2 3 4 5 1= worst it’s ever been, 5= best it has ever beenFor the first month of your program, HOW FREQUENTLY would you like to commit to completing intentional exercise?(Required) # of times/week and duration of sessionsFor the first month of your program, WHERE would you like to complete your intentional exercise?(Required) Gym, group fitness studio, home gym, outdoors etc.If you are hoping to complete home workouts, please include a list of your available equipment, if not simply answer N/A(Required) Yoga ball, dumbbell weights, pull-up bars, jump rope, bosu balls, cable systems, treadmill, bike, etc.For the first month of your program, what kinds of intentional exercises would you be open to completing?(Required) Resistance Training, Group Fitness Classes, Weightlifting, Circuit Training, 1 on 1 Personal Training, Yoga, Walking, Outdoor Running, Let My Coach DecideIf you are hoping to complete your program at a public gym, please include the name of the gym below- if not, simply answer N/A(Required) If you were to set 1-2 personal fitness goals that you hope to achieve in the next year, what would they be?(Required)Nutrition InformationHave you been diagnosed with any food-related allergies? If so, please explain.Please list below any food/food items that you choose to avoid due to digestive upset or personal taste preference(Required)Are you currently taking any specific vitamins or supplements? If so, please list them below.Please list some of your most highly consumed foods.(Required)Do you have a preferred dieting method that has been proven to work for you in the past? If so, please explain.Please list common stores where you complete your grocery shopping.(Required)Ex. Costco, Safeway, Save-On, Wal-Mart, Natural Foods Stores, Supplement Stores.Please describe your typical eating routine/pattern or any insight into your food/eating habits and timing(Required)Ex: Do you consume a large breakfast? Do you drink coffee/tea? Do you eat late at night? Do you fast? Do you skip meals despite being hungry? Do you have medications that require specific meal timing? Do you notice a hunger spike or crash at any specific time?Have you ever tracked your food intake before?(Required)YesNoHow familiar are you with “macros” and “macro counting”?(Required) 1 2 3 4 5 1= poor, 5= excellentDo you wish to implement any macro-tracking during your PF4U program?(Required)YesNoAdditional InformationIf you were to set 1-2 health and wellness goals that you hope to achieve in the next year, what would they be?(Required)Please describe how your ideal coach would best support you in achieving these goals.(Required)Would you like a membership to the Perfectfit4u App © ( $3.99/month) which allows clients to track their food intake and progress as well as receive detailed workout demo videos?(Required)Yes - iPhoneYes - AndroidNoIf so, iPhone or Android?Please list below anything that you may feel is a concern or any information that has not been disclosed that you feel your coaching staff should be made aware of before constructing your PF4U programming.Start PhotosDo you have your start photos ready for upload? If so, upload them below. If not, please email front, back and side profile photos to email@example.com Drop files here or Select files Max. file size: 300 MB, Max. files: 3. *Photos should be taken from a subjective perspective in a well-lit room on a blank backdrop. *Please wear something you can wear consistently for all photos you send to your coach to keep consistencyPAR-QPlease Note: If you have answered YES to any of the PAR-Q question below, it is imperative that Perfectfit4u receives a doctors note (uploaded below) before constructing your training programming. Has your doctor ever said that you have a heart condition or high blood pressure?(Required)NoYesDo you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?(Required)NoYesDo 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).(Required)NoYesHave you ever been diagnosed with another chronic medical condition?(Required)NoYesIf so, please describe.Are you currently taking prescribed medication for a chronic medical condition?(Required)NoYesIf so, 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.(Required)NoYesHas your doctor ever said that your should only do medically supervised physical activity?(Required)NoYesDoctors Note UploadMax. file size: 300 MB.This upload is only required if you have answered YES to any of the above PAR-Q questions. Enter Today's Date(Required) MM slash DD slash YYYY Consent 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.NameThis field is for validation purposes and should be left unchanged.