Coach Ashlyn's Group Intake Form | #Perfectfit4u

Client Intake Form

This is our starting point! This information will be used to design your custom macros for Coach Ashlyn’s group program.

New client information.

Personal Contact Information

Name(Required)

First Last

Phone(Required)

Email(Required)

This is the main source of communication from PF4U Health Coaching. Please double-check your spelling!

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about PF4U?(Required)

If 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.

Please place the following 4 goals in order of importance from MOST important to LEAST important to you at this time (You will be asked this each month as goals can and will change): FAT LOSS, STRENGTH GAIN, MUSCLE GAIN, HIGHER ENERGY/HEALTH/LONGEVITY

(The top/ first item on your list is the MOST important)

Personal Health Information

Birthdate(Required)

Age(Required)

Please enter a number from 12 to 99.

Height(Required)

In feet and inches

Current Weight(Required)

Please enter a number from 75 to 999.

In pounds

Body Fat Percentage

Please 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 FitBit

Are you pregnant?(Required)

Are you breastfeeding?

If you are breastfeeding, please indicate the importance of upkeeping your current milk supply

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)

What 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)

Training Information

How frequently do you take part in physical exercise?(Required)

Number of times/week and length/session

What types of physical exercise do you currently complete?(Required)

These are the types of exercise you are partaking in right now

What 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 wish to complete workouts geared towards fat loss and muscular endurance or do you wish to complete the workouts tailored towards muscle building and strength gains?(Required)

** You will receive a different training regime and macronutrient information based on this decision**

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

Drop files here or

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 consistency

PAR-Q

Please 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)

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

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).(Required)

Have you ever been diagnosed with another chronic medical condition?(Required)

If so, please describe.

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

If 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)

Has your doctor ever said that your should only do medically supervised physical activity?(Required)

Doctors Note Upload

Max. 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)

Comments

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