Client Intake Form Template for Weight Loss Coaching

Use in FirstRep form

Personal Information

Collecting personal details to tailor the coaching experience.

Aa Full Name *

Enter your full name

Aa Email Address *

Enter your email address

Aa Phone Number

Enter your phone number

D Date of Birth *

Current Health Status

Understanding your current health status is vital for personalized coaching.

# Current Weight (lbs) *

Enter your current weight

# Target Weight (lbs) *

Enter your target weight

Aa Height (ft & in) *

Enter your height (e.g., 5'8")

... Any Pre-existing Conditions?

List any health conditions

Dietary Habits

Understanding your eating habits will help create a sustainable nutrition plan.

v Current Diet Type *

... Describe Your Typical Daily Meals *

Detail your usual meals

Y/N Do You Have Food Allergies?

v Snacking Frequency *

Exercise History

Gathering information on your past exercise routines helps in setting realistic goals.

... Current Exercise Routine

Describe your current exercise routine

vv Favorite Types of Exercise

... Previous Weight Loss Attempts

Share details of previous attempts

Motivation & Goals

Clarifying your motivations and goals can boost your commitment.

... Main Motivation for Weight Loss *

What drives you to lose weight?

Aa Weight Loss Goals Timeline *

Desired timeline for achieving goals

... Obstacles You Anticipate

List potential challenges you foresee

... Support System

Do you have a support system in place?

Emotional Eating Patterns

Understanding emotional eating habits helps in creating a comprehensive plan.

Y/N Do You Eat When Stressed? *

... Triggers for Emotional Eating

Identify your triggers

... Coping Strategies Used

What do you do instead of eating?

Why Use This Template

Personalized Coaching

Provides a framework to understand individual client needs.

Goal Setting

Helps in setting realistic and achievable weight loss goals.

How to Use

Fill out each section honestly for best results.

Submit the form to your coach for review.

Customization Tips

Adjust the questions based on specific client needs.
Include additional fields for deeper insights.
Modify the layout for better user experience.

Build and send weight loss coaching templates digitally with FirstRep. Free for up to 3 clients.

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Frequently Asked Questions

How long does the intake process take?

Typically, it takes about 15-30 minutes to complete.

Is my information kept confidential?

Yes, all information is kept private and secure.