Members Only

Welcome, Let's Get Started

Thank you for joining the program! Please complete your confidential Client Intake Form below so we can personalize your journey and support you every step of the way.

Begin My Intake Form

⏱ Estimated time: 15–20 minutes

Why This Form Matters

The more we know about your lifestyle, health, and goals, the better we can tailor your program to help you succeed.

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Personalized Support

Your answers help us design a plan that fits your unique goals and lifestyle.

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100% Confidential

All information is stored securely and used only to support your progress.

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Track Progress

Establish your baseline so we can celebrate every milestone together.

Client Intake Form

Please complete every section as thoroughly as possible. Your responses are confidential and will be reviewed by Jane before your first session.

Before you begin: Have your recent health details, typical meals, and goals in mind. You'll be asked about your lifestyle, physical activity, weight & nutrition history, and personal insights.
Work Environment*
Job Activity Level*
Hours on Computer Per Day*
Sleep Per Night (hours)*
Sleep Quality*
Daily Stress Level*
How Do You Relieve Stress?
Recent Major Life Changes?*
Explain Recent Major Life Changes
Use Wearable/Trackable Devices or Apps?*
Which Devices/Apps? (e.g., Fitbit, Apple Watch, Oura Ring, Strava, MyFitnessPal)
Health History & Current Situation
Strenuous Exercise Days Per Week (15+ minutes)*
Moderate Exercise Days Per Week (15+ minutes)*
Mild/Light Exercise Days Per Week (15+ minutes)*
Regular Physical Activities (at least 2-3 times per week)
How Long Have You Been Exercising?*
Long-Term Goals (at least 2)*
Short-Term Goals (at least 2)*
Additional Goal Information
I've never been a person who sets clear goals.*
My friends support my interests and efforts.*
When physical activities get stressful, I stop them.*
I'm good at applying myself to new tasks.*
My family members support my interests and efforts.*
I can persist when a task is tiring, uncomfortable, and/or painful.*
I find it difficult using 'self-control' to keep myself successful.*
I don't like to overextend myself physically.*
I don't have people around who support my interests and efforts.*
Currently in a Weight-Loss Program?*
Explain Weight-Loss Program
How Long at Current Weight?
Recent Weight Changes
Eat Fruit Daily?*
Servings of Fruit Per Day
Eat Vegetables Daily?*
Servings of Vegetables Per Day
I affirm that the information provided is accurate and understand this is voluntary participation, not medical service. I agree to obtain medical clearance if needed.*
draw your signature
I understand I will complete validated surveys to assess behavioral and psychological constructs and acknowledge these help tailor the program to my needs.*
draw your signature
I understand it's recommended to consult a healthcare provider before starting exercise and acknowledge the PAR-Q+ screening tool. I agree to complete it.*
draw your signature

What's Included in the Form

Here's a quick overview of the sections you'll complete:

SECTION 1

Client Info & Lifestyle

Contact details, occupation, sleep, stress, and daily routine.

SECTION 2

Health & Activity

Health history, exercise habits, and current physical activity level.

SECTION 3

Goals & Insight

Short and long-term goals plus personal insight questions.

SECTION 4

Nutrition & Consent

Weight history, typical meals, and required program consents.

Frequently Asked Questions

Everything you need to know before completing your intake.

How long will this take?
Most members complete the form in 15–20 minutes. Take your time — accurate answers help us serve you better.
Is my information kept private?
Yes. All information is confidential and used only to personalize your program and track your progress.
What is the PAR-Q+ and do I need it?
The PAR-Q+ is an internationally recognized health screening tool. Please complete it at eparmedx.com/par-q/ before beginning physical activity.
What happens after I submit?
Jane will review your responses and reach out to schedule your first virtual session and outline your customized plan.
Need help completing the form?
Reach out anytime at support@yourhealthfitplan.com — we're happy to walk you through it.

Ready to Take the First Step?

Your personalized program begins the moment you submit your intake form. Let's build a plan that's uniquely yours, Jane is ready to guide you.

Complete My Intake Form

Questions? Email support@yourhealthfitplan.com