Client Intake Form Template for Menopause & Perimenopause Fitness

Use in FirstRep form

Personal Information

Gathering personal information helps tailor fitness programs to individual needs.

Aa Full Name *

Enter your full name

# Age *

Enter your age

Aa Email Address *

Enter your email

Health History

Understanding your health history is crucial for effective fitness planning.

Y/N Are you currently experiencing hot flashes? *

Y/N Have you been diagnosed with any hormonal imbalances? *

Y/N Do you have any existing joint pain? *

... List any medications you are currently taking

Enter medication names

Fitness Goals

Identifying your goals helps in creating a personalized fitness plan.

vv What are your primary fitness goals? *

# How many times per week do you currently exercise? *

Enter number of days

... What types of exercise do you enjoy?

List your favorite activities

Lifestyle Factors

Understanding your lifestyle helps us to create a sustainable fitness plan.

# How many hours of sleep do you get on average? *

Enter hours of sleep

Y/N Do you have a balanced diet? *

1-10 Rate your stress levels (1-10) *

Exercise Preferences

Understanding your preferences ensures adherence to the fitness program.

v Do you prefer working out alone or in a group? *

v What time of day do you prefer to exercise? *

... Any physical activities you wish to avoid?

List activities to avoid

Why Use This Template

Personalization

A personalized approach addresses unique hormonal changes.

Goal Setting

Setting clear goals enhances motivation and commitment.

How to Use

Fill out the form completely to ensure accurate assessment.

Submit the form to receive your personalized fitness plan.

Customization Tips

Include specific dietary restrictions relevant to menopause.
Add space for personal fitness milestones.
Incorporate questions about stress management techniques.

Build and send menopause & perimenopause fitness templates digitally with FirstRep. Free for up to 3 clients.

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Frequently Asked Questions

What should I do if I have more health concerns?

Please discuss any additional health concerns with your coach for tailored advice.

How often should I update my intake form?

It's recommended to update your intake form every 3-6 months or as your situation changes.