Complete Coaching Package Intake Form

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

General Health

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness or injury?

Yes

If you answered yes to any of the questions above, please supply additional information.

Are you currently working with any other healthcare or wellness providers that you would like me to collaborate with (e.g., physician, physical therapist, dietitian, therapist)? If yes, please provide their information below:

Are you currently taking any medications or supplements? If yes, please list them.

Do you have any known food allergies or intolerances? If yes, please specify.

Do you currently follow any specific dietary pattern (vegan, vegetarian, gluten free, etc.)?

Tell me about any past or current injuries.

What is your everyday life like (work/kids/school/other hobbies/commitments)?

Is there a recurring day and time you would like to schedule for our bi-weekly video or phone call? If you don’t want bi-weekly please indicate a frequency that would work for you (you can change this anytime in the future).

On average, how many hours of sleep do you get per night?

If applicable, do you track your cycle?

If applicable, do you feel your menstrual cycle impacts your daily life and/or training?

Nutrition

What does a typical day of meals and snacks look like for you?

How consistent is your daily routine (meals, sleep, schedule)?

How would you describe your current stress levels?

Low

Medium

High

How would you describe your current stress levels?

How would you describe your overall energy levels throughout the day?

Do you track your food intake or any health data (macros, calories, weight, sleep, etc.)?

What foods or eating patterns make you feel your best? What tends to make you feel worse?

Do you experience digestive issues, energy crashes, or strong cravings regularly? If yes, please describe.

How would you describe your current relationship with food?

Do you ever feel guilt, stress, or anxiety around eating?

Have you ever worked with a nutritionist, dietitian, or coach before? If so, what was that experience like?

Do you have any history of disordered eating or restrictive patterns you’d like me to be aware of?

What are your main goals for nutrition or health coaching? Examples: improve energy, better balance, consistent meals, gut health, body composition, stress management, etc.

What feels most challenging for you right now when it comes to nutrition or lifestyle habits?

Exercise

Broadly, what is your general athletic history?

Tell me specifically about your running history. How did you find the sport, how long have you done it, etc.

Tell me specifically about your strength training history. Are you using strength to complement an existing sport or hobby? How did you find the sport, how long have you done it, etc.

What does your typical training week look like? What would you like it to look like?

How many days per week do you want to train? How many days per week do you want for rest? How many days per week are you doing something else?

Which day of the week is best for your long run? If you work a typical M-F schedule, is Saturday or Sunday best for you?

Any other scheduling notes (i.e. do you travel often, does your schedule change season to season)?

How competitive would you describe yourself as?

What are your weaknesses as an athlete (specific technique, areas where you're weaker, etc)?

What are your strengths as a athlete (movements you do best, areas of training that you like and/or excel in)?

Describe some things that went well and failure points from previous training or racing.

Have you worked with a coach before? If so, what did you enjoy and what did you wish was different?

Have you ever done strength training?

What type of gym equipment do you have access to? A full gym, free weights, etc?

What other types of activities do you do (cycling, swimming, yoga, etc.)?

Do you have experience doing “speed work” and how do you feel about it?

Are you currently signed up for any races or events?

What are your short-term goals (next 3–6 months)?

What are your long-term goals (6+ months)?

Is there anything else I should know about you?

Initials

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