Intake

Address *

Line 1

Line 2

City

State

Zip Code

Country

Sex *

Male Female Prefer not to say

What medical concerns (e.g., recent surgery, pregnancy), if any, do you have at the present time? *

Have you ever had any injuries or chronic pain? If yes, please explain. *

Have you ever had any surgeries? If yes, please explain. *

Has a medical doctor ever diagnosed you with a chronic disease (heart disease, high cholesterol, diabetes, high blood pressure)? If yes, please explain. *

Has your doctor ever said that you have a heart condition & that you should only perform physical activities recommended by a doctor? *

Yes No

Do you feel pain in your chest when you perform physical activities? *

Yes No

Have you had chest pain in the last month when you were not performing any physical activity? *

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes No

Do you have bone or joint problems that could be worse by changing your physical activity? *

Yes No

Is your doctor currently prescribing any medications for blood pressure or heart conditions? *

Yes No

Any other reasons why you should not engage in physical activity? *

Yes No

Do you use tobacco in any way? *

Yes No

Did you recently stop smoking? *

Yes No

Do you enjoy physical activity? *

Yes No

List any food allergies or intolerances. If none, please state "none". *

Please list any prescribed, over-the-counter, herbal, recreational drugs, or vitamin/mineral supplements you're currently taking. Or state "none". *

How often do you work out per week? *

Do you work out more than once a day? *

Yes No

What are your hobbies (reading, video games, etc.)? If none, please state "none". *

What are your goals - Fitness, Nutrition, Lifestyle? *

What are your expectations from DannyTheCoach? *

Why are your goals important to you? *

When you accomplish these goals, how will your life be different? *

What would it make more important? *

What could improve your confidence? *

If you don't accomplish these goals, how will this affect your life? *

Are you ready & willing to make these changes now? *

Yes No

Do you follow a special dietary plan, such as, low cholesterol, kosher, vegetarian? If none, please state "none". *

Have you ever followed a special diet? *

Yes No

Do you have any problems purchasing foods that you want to buy? *

Yes No

Are there certain foods that you do not eat? *

Yes No

Do you eat at regular times each day? *

Yes No

What foods do you particularly like? If none, please state "none". *

How much water do you drink PER day? *

Do you drink alcohol? *

Yes No

What change would you like to make? *

Please add any additional information you feel may be relevant to understanding your nutritional health and overall lifestyle. If none, please state "none". *

In order to tailor your counseling experience to your needs, it helps to know your expectations. Check one of the following to indicate the amount of structure you would need: *

Tell me exactly what to eat for all my meals and snacks. I want a detailed food plan. I want a lot of structure but freedom to select foods. I want some structure and freedom to select foods. I don’t want a diet. I just want to eat better. Other None

Highest level of formal education? *

How many people in your household? *

Present marital status? *

Who prepares most of the meals in your home? *

How often do you eat out per week? *

If you eat out, where? If you don't eat out, please state "I don't eat out". *

Have you made any food changes in your life you feel good about? *

Yes No

Who could support & encourage you to make these changes? *

INTAKE FORM

Personal Intake Form

CONFIDENTIALITY NOTICE: ALL OF YOUR INFORMATION IS SECURED, CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANYBODY. This data helps DannyTheCoach to formulate a plan of action.

Who we are

What we do

How to contact

Want Us to Contact You?

INTAKE FORM

Personal Intake FormCONFIDENTIALITY NOTICE: ALL OF YOUR INFORMATION IS SECURED, CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANYBODY. This data helps DannyTheCoach to formulate a plan of action.

Who we are

What we do

How to contact

Want Us to Contact You?

Personal Intake Form

CONFIDENTIALITY NOTICE: ALL OF YOUR INFORMATION IS SECURED, CONFIDENTIAL AND WILL NEVER BE SHARED WITH ANYBODY. This data helps DannyTheCoach to formulate a plan of action.