Client Intake Form Template for PCOS & Hormonal Fitness

Use in FirstRep form

Personal Information

Collecting personal data helps tailor the fitness plan to your individual needs.

Aa Name *

Enter your full name

# Age *

Enter your age

Aa Email *

Enter your email address

Health History

Understanding your health history is crucial for designing a suitable fitness regimen.

D PCOS diagnosis date *

Select your diagnosis date

... Current medications

List your current medications

... Other health conditions

List other health conditions (if any)

Symptoms and Concerns

Identifying your symptoms helps in managing your fitness approach effectively.

vv Current symptoms *

Select your current symptoms

1-10 Energy levels *

Rate your energy levels (1-10)

Exercise History

Your past experiences with exercise can influence future recommendations.

... Current exercise routine

Describe your current exercise routine

vv Preferred types of exercise *

Select your preferred types of exercise

# Exercise frequency *

How many days per week do you exercise?

Nutrition and Lifestyle

Understanding your nutrition and lifestyle can help us address hormonal issues effectively.

... Dietary restrictions

List any dietary restrictions or preferences

1-10 Hydration habits *

Rate your hydration habits (1-10)

1-10 Sleep quality *

Rate your sleep quality (1-10)

Goals and Expectations

Defining your goals helps us align your fitness plan with your aspirations.

v Primary fitness goal *

Select your primary fitness goal

... What do you hope to achieve? *

Describe your expectations from this program

Why Use This Template

Tailored Fitness Plans

Personalized fitness plans can significantly improve symptom management.

Track Progress

Regular assessments can help track changes in symptoms and fitness levels.

How to Use

Fill out the form completely to ensure the best possible plan.

Be honest about your symptoms and lifestyle for accurate recommendations.

Customization Tips

Include specific questions about hormonal treatments for a more tailored approach.
Add sections on mental health to address emotional aspects of PCOS.
Incorporate a feedback loop for ongoing assessment of the client's progress.

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

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Frequently Asked Questions

How can exercise help with PCOS?

Exercise can help regulate menstrual cycles, improve insulin sensitivity, and manage weight—key factors in PCOS.

What types of exercise are best for PCOS?

A combination of cardio, strength training, and flexibility exercises is often recommended for optimal results.