Client Intake Questionnaire Name * First Name Last Name Gender * Male Female What is your current relationship status? Single In a relationship Married Divorced Other Do you want to find love or improve your current relationship? Yes No Do you drink alcohol? Yes No If yes, would you like to reduce or eliminate alcohol from your life? Yes No Do you smoke or vape? Yes No If yes, are you interested in quitting? Yes No Nutrition & Fitness How would you describe your current eating habits? Healthy and balanced Somewhat healthy, but inconsistent Unhealthy and need help improving Do you have any dietary restrictions or preferences? How often do you cook at home? Daily A few times per week Rarely Do you grocery shop with a plan, or do you find it stressful? How would you describe your fitness level? Beginner (Rarely exercise) Intermediate (Exercise 1-3 times per week) Advanced (Exercise 4+ times per week) What type of workouts do you prefer? (Select all that apply) Strength training Cardio Yoga/Pilates Outdoor activities (hiking, cycling, etc.) Other Do you have any injuries, pain or health conditions that impact your ability to exercise? Yes No If Yes, Please specify Daily Habits & Mental Well-being On average, how many hours of sleep do you get per night? Do you wake up feeling rested? Yes No How many hours per day do you spend sitting? How much time do you spend daily on screens (TV, social media, phone use)? Do you feel social media negatively impacts your mental health? Yes No Do you struggle with stress or anxiety? Yes No What activities help you relax and de-stress? Work & Stress What do you do for work? How would you describe your job satisfaction? I love my job It’s okay, but I’d like to improve some aspects I don’t like my job, but I tolerate it I dislike my job and want to leave Are you currently looking for a new job or career change? Yes No How would you rate your stress levels on a scale from 1 to 10? (1 = No stress, 10 = Extremely stressed) 1 = No stress 10 = Extremely Stressed What are your biggest sources of stress in daily life? How do you currently manage stress? Goal Setting & Vision What are your fitness and health goals? (Select all that apply) Lose weight Gain muscle Increase energy levels Improve sleep Reduce stress Improve overall well-being Other What are your personal goals? One-week goals? One-month goals? Six-month goals? One-year goals? Where do you see yourself in five years in terms of health, relationships, and overall Imagine yourself as an 80-year-old version of you—what would be your biggest regrets if you don’t make changes now? Thank you!