Program Type (Check all that apply):
Individual Weight Management Program
Group Weight Management Program
Online/Remote Program
In-Person Program
Hybrid Program (Online + In-Person)
Meal Planning Services
Fitness Coaching
Behavioral Counseling
Nutritional Counseling
Medical Weight Management (e.g., supervised by a physician)
Maintenance/Follow-Up Program
Other (please specify):
First Name
Last Name
Date of Birth
Gender
Phone Number
Email Address
Full Name
Phone Number
Relationship
Current Weight (lbs/kg):
Height (ft/cm):
Goal Weight (lbs/kg):
Have you been diagnosed with any of the following? (Check all that apply):
Diabetes
Hypertension (High Blood Pressure)
High Cholesterol
Heart Disease
Thyroid Disorder
Eating Disorder (e.g., anorexia, bulimia, binge eating)
Food Allergies/Intolerances
Other (please specify):
Are you currently taking any medications?
Do you have any physical limitations or injuries that may affect your ability to exercise?
Have you had any recent surgeries or hospitalizations?
Do you smoke or use tobacco products?
Do you consume alcohol?
Are you pregnant or breastfeeding?
How would you describe your current activity level?
Sedentary (little to no exercise)
Lightly Active (light exercise 1-3 days/week)
Moderately Active (moderate exercise 3-5 days/week)
Very Active (intense exercise 6-7 days/week)
What types of physical activity do you enjoy? (Check all that apply):
Walking
Running/Jogging
Weight Training
Yoga/Pilates
Swimming
Cycling
Group Fitness Classes
Other (please specify):
How many hours of sleep do you get per night on average?
Less than 5 hours
5-7 hours
7-9 hours
More than 9 hours
How would you describe your stress levels?
Low
Moderate
High
Do you currently track your food intake or exercise?
What is your typical daily diet like? (Check all that apply):
High in processed foods
High in fruits and vegetables
High in protein
High in carbohydrates
High in fats
Balanced diet
Other (please specify):
Do you follow any specific dietary patterns or restrictions?
Vegetarian
Vegan
Gluten-Free
Low-Carb/Keto
Paleo
Mediterranean
Other (please specify):
How many meals do you eat per day?
1-2
3
4 or more
Other (please specify):
Do you snack between meals?
Do you drink enough water daily?
What is your primary goal for joining this program? (Check all that apply):
Lose Weight
Gain Muscle
Improve Overall Health
Manage a Medical Condition
Improve Fitness Level
Learn Healthy Eating Habits
Other (please specify):
What is your timeline for achieving your goal?
1-3 months
3-6 months
6-12 months
Ongoing
Have you tried any weight management programs before?
What challenges have you faced in achieving your weight goals?
Lack of Motivation
Time Constraints
Emotional Eating
Lack of Knowledge
Other (please specify):
Do you prefer individual or group sessions?
Individual
Group
No Preference
How much time can you commit to the program weekly?
Less than 2 hours
2-5 hours
5-10 hours
More than 10 hours
Are you comfortable with regular weigh-ins and progress tracking?
Do you have access to the necessary tools for the program (e.g., smartphone, scale, kitchen equipment)?
Are you willing to make long-term lifestyle changes?
Do you have any concerns or reservations about the program?
I understand that this program involves dietary and/or exercise changes and that I should consult my healthcare provider before starting.
I agree to provide accurate information about my health and lifestyle.
I understand that my progress will be monitored and that I may be asked to provide updates on my weight, diet, and activity levels.
Client Signature:
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
Client Intake Form, explaining the purpose and importance of each section, as well as how the information gathered can be used to design a personalized and effective weight management program.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation section before publishing.
The mandatory questions are those that ensure safety, legal compliance, and program suitability. Below are the essential questions that should never be omitted, along with the reasons why they are required.
Mandatory questions focus on safety, legal compliance, and baseline metrics. The rest can be adjusted based on program depth, but skipping core health/consent questions is not advisable.