Client Intake and History

TITUS FITNESS PERFORMANCE

Name

First Name

Last Name

Phone

(###)

###

####

Age

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Height

Weight

1RM Bench | 1RM Squat | 1 RM Deadlift

If applicable - not everyone is concerned with these numbers. If this is not a concern for you, you may leave this space blank.

Occupation

Length of Employment

PRESENT COMPLAINTS

1. What is your main fitness, nutrition and/or health concern(s)?

2. If we were to sit down with a friend and discuss potential solutions to your current nutrition or health concerns what would they be?

3. What potential barriers do you foresee that would prevent you from enacting these solutions?

4. Do you feel it is possible to eliminate, manipulate, or prevent these potential barriers?

5. What are your strengths that will enable you to accomplish your goals?

6. What does your physical movement practice look like? How many days a week do you currently train? What type of physical activity do you enjoy?

7. What has worked for you in the past? When working with a mentor or coach have you responded better to personalized advice or guidance?

9. Rate on a scale of 1-10:

How important is it for you to resolve your health or nutrition concerns?

Do you feel that you are coachable and would enjoy a mentor in helping you?

Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?

Injuries/Surgeries/Hospitalizations

N/A if this does not apply to you.

Date of Injuries/Surgeries/Hospitalizations

If applicable, I would just like a general idea of when it happened - place the number (1) for the day...I don't need the specific day.

YYYY

Past/Recent Illness

This would be something serious like Lyme disease, for example. N/A if this does not apply to you.

Date of Past/Recent Illness

If applicable, I would just like a general idea of when it happened - place the number (1) for the day...I don't need the specific day.

YYYY

Trauma

N/A if this does not apply to you.

Date of Trauma

If applicable, I would just like a general idea of when it happened - place the number (1) for the day

YYYY

Family History (mother, father, siblings, spouse, children)

Please list any history of conditions within your family and/or any condition with your immediate family that may affect your training.

Children/ages:

DO YOU USE:

Alcohol

Yes

drinks/week

Tobacco

Yes

pack/day

Caffeine

Yes

cups/day