Client intake form

Comprehensive Client Intake & Application Form

Please complete this form thoroughly prior to your consultation or program start. All information is confidential and stored securely.

Section 1: Personal Details

First name

Last name

Date of Birth

Day

Month

Year

Mobile Number

Gender

Occupation

Bodyweight (kg)

Height (cm)

Waist Measurement (cm)

Blook Pressure

Section 2: Medical & Health History

List any chronic illnesses or medical conditions:

Past surgeries or hospitalizations (with dates):

Family medical history (notable conditions):

Current medications (include dosage):

Current supplements (include dosage/brand):

Do you have any current or past injuries (e.g., back, shoulders, knees)?

Section 3: Lifestyle & Training History

Describe your typical weekly exercise routine:

How many days per week are you currently training?

Training experience:

Nutrition/dietary habits (e.g., special diets, restrictions):

Average hours of sleep per night:

Alcohol consumption (frequency/amount):

Tobacco or other substance use:

Section 4: Health & Fitness Goals

What are your primary health and fitness goals? (e.g., performance, longevity, aesthetics, disease management)

What is your main goal for the next 8–12 weeks?

Are there specific symptoms or concerns you wish to address?

Are you currently using or considering Testosterone or any other hormone medications?

Section 5: Previous Medication & PED History

List any medications you have taken in the past (include name, dosage, duration, reason):

Have you ever experienced adverse reactions or side effects from any medications? (If yes, please describe):

Have you previously used Testosterone, Anabolic/Androgenic Steroids, or any other PEDs? (If yes, provide details):

Section 6: Previous Lab Work

Have you had blood tests or relevant labs in the past 12 months?

Yes

If yes, please email them prior to your consultation or program start.

Section 7: Additional Information

Is there anything else relevant to your consultation or coaching?

Section 8: Program Commitment & Consent

I understand the commitment required for this program/service, including attendance, payment, and providing accurate health information.

I acknowledge that results depend on my own effort, consistency, and adherence to the agreed plan.

I agree to provide accurate information about my health, injuries, and medical history.

I understand all information is confidential and will be used solely for the purpose of providing professional services.

By signing below, I confirm that I have read and understood the above and wish to proceed.

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