Coaching Intake Form

Name*
Height, Weight & Age*
What is your occupation and what is your favorite hobby?*
What is your work schedule like? Does it interfere with training, nutrition, time management or sleep?*
What does your current training/exercise routine look like? Frequency, training types and modalities used?*
Are you doing any cardio? If so, how much and what type? Do you enjoy it?*
What time of day do you prefer to train?*
What is your current nutrition intake like? (Please provide foods, times you eat, frequency and etc). If you are already tracking macros/calories, please provide them below.*
What is your biggest struggle with nutrition?*
What have been the biggest successes for you? (diets, training styles and etc)*
What are your goals for the next 3 months, 1 year and 5 years? Why are you here?*
Why are those goals important to you? What about them excites you? Who else do they impact?*
Any food allergies, injuries, diseases or serious limitations I should know about?*
How many alcoholic beverages do you consume weekly?*
When was the last time you had your blood panels and hormones checked? Do you have any information that would possibly detract from your desired results?*
What, if any, supplements are you currenlty taking?*
How can I be the most helpful, enjoyable coach possible?*
List anything else you think I would benefit from knowing. (could be things like favorite movies, music, memes or quirks)*
Email*
Phone

Cody Gualtieri
Fitness & Nutrition Coach
CPT, CES, NCI, BNB 1&2

Midpoint Fitness
405 N Wickham Rd
Suite 106
Melbourne FL 32935
321-720-7868