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FWL Intake Form
Let's get strong 🎉
Contact information
Name
(Required)
Pronouns
(Required)
She/her/hers
He/him/his
They/them/their
Other (if you're comfortable, specify in the last question of the form!)
Date of birth
(Required)
DD slash MM slash YYYY
Phone number
(Required)
Email
(Required)
Instagram handle
Occupation
Emergency contact name
(Required)
Emergency phone number
(Required)
Medical history
Are you currently taking any medications or supplements? If you’re comfortable, please specify type, dosage, and reason.
(Required)
Do you have a (family) history of heart trouble, high blood pressure, asthma or diabetes?
(Required)
Have you been hospitalized for any reason? If so, please explain.
(Required)
Do you have any other medical conditions that have not been mentioned so far that are relevant to your fitness journey?
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Health & Fitness
How would you describe your overall physical health?
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How would you describe your daily activity level (intense/moderate/sedentary)? Why?
(Required)
What degree of stress are you under on a scale of 1-10 (10 is highly stressed)? Why?
(Required)
Do you currently follow a specific nutrition plan or way of eating? If yes, please explain.
(Required)
How often do you take part in physical exercise?
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If your participation in exercise is lower than you would like it to be, why is that?
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Have you ever played any sports before? Which ones and for how long?
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Developing your program
What are your goals for the next 3 – 12 months? (ex: develop strength, build muscle, improve conditioning, rehab an injury)
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How long have you been thinking of these goals?
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What do you feel are the obstacles that could challenge your journey to your goals?
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If you achieved these goals, how would you feel?
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What are your favourite fitness activities? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)
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What are your LEAST favourite fitness activities? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)
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Realistically, how often would you like to exercise together?
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What are the best days/times during the week for you to commit to your program?
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Our coaching relationship
Why do you want to work with a trainer?
(Required)
Describe your ideal coaching relationship? What is my role in your nutrition journey?
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How can I help you reach the goals you listed?
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Anything else you’d like me to know about you? Personality? Needs? Anything that helps me get a better sense of YOU is encouraged 🙂
(Required)
Acknowledgment, participant release & cancelation policy
Consent
By checking the boxes below, I acknowledge and agree to the terms as stated below.
Consent
I understand and agree that it is my responsibility to inform Fit With Lou of any condition or changes in my health that might affect my ability to complete the program safely.
Consent
I agree that Fit With Lou shall not be liable or responsible for any injuries to me resulting from my participation and I expressly release and discharge Fit With Lou from all claims, actions or judgments as a result of any injury or damage which may occur in connection with my participation.
Consent
I understand that Fit With Lou operates on a scheduled hourly appointment basis and that I must provide a minimum of 24 hours notice if I need to reschedule an appointment. Where less than 24 hours notice is given, I understand that rescheduling will not be possible. My coach will utilize that time to further develop my program.
Consent
I understand that all rescheduled appointments must be used within the same calendar month as the original appointment, subject to the availability of my coach. If a mutual time can not be found to reschedule, the appointment will be forfeited.
Consent
I agree to an initial 3-month commitment to coaching with Fit With Lou. After three months, I understand my contract will automatically renew on a month-to-month basis. I agree to give notice of 1 calendar month via email to hello@withlou.com in order to cancel the contract. I acknowledge that there are no refunds available on this investment.
Phone
This field is for validation purposes and should be left unchanged.