Client Intake Form | Fitness Reloaded

Thanks for booking your appointment!
Step 2 out of 2: Fill out the Habits Intake Form.

It is my sole objective to help you lose weight so I’m really excited you’re here with us! To complete your setup and also get access to the website there’s one more step left – to fill out our Intake Form and let our staff know more about you, save time on our appointment, and also create the right Habit Diary for you.

So let’s not delay:

Let's start making your Weight Loss Habits Plan

At Fitness Reloaded we don't just address the weight (the symptom), we also address the habits and behaviors that drive it. Please answer the following questions about your current habits so that we know more about you and start working on your plan before we even meet! Your answers are confidential and will not be shared with anyone outside of Fitness Reloaded LLC. See you in our appointment!
Habit Analysis

Let's review the most common daily habits that affect your health and your weight.
On a typical day, how many fruit servings are you eating (e.g., 1 apple, or 1 cup of grapes)? Please do not count fruit juice. *

2 0 to 1 1 to 2 2 to 3 3 or more
On a typical week, how many alcoholic drinks are you consuming? *

I rarely drink 2 or less 3 to 4 5 to 7 8 or more
What do you do for weekday lunches? Do you eat out? Do you have a cafeteria at work? Do you eat last night's dinners leftovers? Maybe you prepare separate lunches and eat those? Or maybe a combination of these? Also: How happy are you with your current routine? *
How often in a typical week are you cooking at home? Are you the main cook in your household? If yes, are you cooking just for yourself or do you also have to cook for others? And finally, do you try to cook once and produce multiple meals for multiple days (batch cooking) or are you leaning towards cooking on a daily basis? If you're rarely cooking, what has prevented you from making it happen? *
How often do you eat out on a typical week? For "eating out", please also count dinner parties at friend's places or getting invited to your in laws for a BBQ. So an example answer could look like - twice a week you have lunch with your coworkers at a cafe, then once a week you have date night, on Sunday you do Sunday brunch with your friends, and usually there is a BBQ or pizza-based event that you have to attend on the weekend. *
Do you find yourself compelled to eat without actually being hungry? E.g., you go to the office's kitchen for coffee and leave with a muffin as well. Or maybe you feel the need to munch on something while watching TV. Or if you're having dinner, you'll keep on going even though you're no longer hungry. Or you'll snack way more when you're stressed. What are some common patterns for you, and in a typical week, how often are you doing these? *
Do you exercise? If yes, how many times do you exercise in a typical week and what does your routine look like? Also: how happy are you with your current routine? *
Do you go into "pity-party" mode when you eat something you "shouldn't"? And if yes, does that make you eat even more? E.g., say you eat a cookie, now you feel guilty, then think "whatever" and go on to eat the whole box. If that is a thing, how often in a typical month would you say you do this type of behavior? *
One-Day Food Diary

Please reflect back to yesterday (or even today if you're completing this late at night) and let us know what you ate. Don't feel self-consious! This is to get a better glimpse of where you're at right now and how we might help you.
What day in the week was it? *

Mon Tue Wed Thu Fri Sat Sun
What did you have early in the morning? E.g., coffee with cream at 6 am, two slices of french toast at 9 am with strawberries. *

Also let us know - is this typical for you or out of the ordinary?
What did you have for lunch? If you skipped a meal, then just say so. *

Also let us know - is this typical for you or out of the ordinary?
Did you have an afternoon snack? If yes, what? *

Also let us know - is this typical for you or out of the ordinary?
What did you have for dinner? What time? *

Also let us know - is this typical for you or out of the ordinary?
Did you eat after dinnertime? If yes, what? *

Also let us know - is this typical for you or out of the ordinary?
You're almost done!

Thanks for completing this form. It'll help us work on your Weight Loss Habits Plan so we are ready to go on our appointment!
Email Address *
Name *

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Once you click to submit the intake form, you will receive an email from us with your autogenerated password so you can get access to the website immediately.

If you don’t immediately see an email from us then please check your SPAM folder, just in case our emails our calendar invites got trapped there. If you have a question or need anything at all, then just shoot an email to Tiffani at support@fitnessreloaded.com and she’ll take care of you.

See you soon!

Thanks for booking your appointment! Step 2 out of 2: Fill out the Habits Intake Form.

Let's start making your Weight Loss Habits Plan

Habit Analysis

One-Day Food Diary

You're almost done!

Thanks for booking your appointment!
Step 2 out of 2: Fill out the Habits Intake Form.