Momentum Client Intake Form

Little Feet Welcome. Big Goals Encouraged.

Thank you for trusting us to be part of your wellness journey! Please take a few minutes to complete this form so we can best support you.

Contact Information

First name or Preferred Name

Last name

Email

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Emergency Contact (Name & Number)

Family & Lifestyle

Do you have children? (if yes, list ages)

Are you currently pregnant or postpartum? (If so, how far along / how old is your baby?

Occupation

Typical daily schedule (work hours, childcare, activities)

Health History

Do you currently have or have you ever had any of the following? (check all that apply)

Are you currently under a healthcare provider's care for any condition?

Are you cleared for exercise by your healthcare provider?

Activity

Describe your current activity level

Sedentary

Lightly active (1-2 days/week)

Moderately active (3-4 days/week)

Very active (5+ days/week)

What types of movement do you enjoy?

Do you have any movement limitations or injuries?

Are you currently following any fitness program or workout? (if yes, please describe)

Nutrition Habits

Describe a typical day of eating for you (meals, snacks, drinks)

Do you currently follow a specific eating pattern/diet? (e.g. vegetarian, intermittent fasting, KETO)

How long have you been eating how you do now as far as calorie intake or general nutrition habits?

If you know, what is your current calorie intake and/or macros?

How much water to do you consume (oz)?

What is your caffeine intake like?

If alcohol is part of your diet, how much and how often?

What experience do you have with tracking your food?

Are you currently tracking food intake?

Calories

Macros

Food journal

Other

Please state all successful/unsuccessful diets you've tried in the past.

Do you have a history of eating disorders?

Do you avoid or restrict any foods?

How would you describe your relationship with food?

Goals & Motivation

What inspired you to join Momentum?

List your top 3 health & wellness goals

What barriers or challenges have kept you from reaching these goals in the past?

On a scale of 1-10, how ready are you to make sustainable lifestyle changes? (1 = not ready, 10 = all in)

Overall Wellbeing

Age, Height (in), Weight (lbs)

On average, how many hours of sleep do you get each night?

How often is your sleep interrupted?

Do you have an abnormal sleep schedule due to work or other commitments?

Do you typically feel rested?

Yes

No

Other

What is your go-to for stress management?

Do you have regular, normal bowel movements 1-2x a day? If not, please explain if they are loose, hard to pass, and frequency.

Are you on birth control? If so, what type and how long?

Do you have a regular menstrual cycle with 5-7 days of flow? If not, please explain/describe.

What PMS or period symptoms do you typically have?

Support & Preferences

Do you prefer:

Individual coaching only

Group support

A mix of both

Anything else you'd like your coach to know about you, your family, or your wellness journey?

What workout equipment do you have at home?