Sheena Giordano

Certified Fitness Trainer

Intake Form

Please fill out fully to the best of your ability

First Name *

Last Name *

Address

City

State

Postal code

Country

Phone *

Email *

If you are a referral from a current client, please enter their name below

Gender Identity

What is your Height?

What is your Weight?

Weight in

Pounds

Kilos

Do you know your body fat percentage?

Yes

No

If yes, enter your body fat percentage below.

Date of birth

Do you currently exercise?

Yes

No

If yes, what are you currently doing, how often, what is the duration, and what would you rate the intensity (1-10, 1 being very easy and 10 being extremely challenging)

Do you work out at home or at the gym?

Home

Gym

Both

If you work out at home, what equipment do you have?

What is your primary goal right now?

Fat loss

Build Muscle (Hypertrophy)

Increased Strength

Overall Health and More Energy

Which of these options best describes your current goal?

Overall weight loss while maintaining/SLIGHTLY increasing muscle mass

Happy with current weight but, want to reduce body fat to see definition in muscle mass

Happy with current body but, want to see an increase in muscle mass

If you chose weight loss, how much weight would you like to lose?

If you chose muscle, how much muscle would you like to put on?

What is your ideal body weight?

What is your 3 month goal?

What is your 6 month goal?

What is your 12 month goal?

Do you have any limitations or preferences when it comes to working out?

How many days per week can you commit to exercising consistently? At what duration?

Please list any current or past medical conditions

List all healthy foods that you enjoy.

List any foods that you dislike.

Are you allergic to any foods or are there any foods you really do NOT want in your meal plan?

What have you noticed that you struggle with the most?

Nutrition

Exercise

What have you noticed helps you stay on track with a workout and nutrition program?

Why do you want to achieve these results? What will this do for you? (Be specific; more confidence, better health, look better in clothes, increased energy, etc.)

Would you feel comfortable with me using progress pics on social media?

Yes

No

Yes, but don't use my face

Sheena Giordano

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