Get Started Intake form - The OMNI FIT: Fit Me Forever

Welcome! Tell us about yourself.

We want to get to know you.

Understanding where you’re coming from and what your goals are will help us continue to design programs that will get you where you want to go. We’re in this together, starting today.

Complete all the questions today.

Try to complete the entire questionnaire in one sitting to avoid having to start over from the beginning. It should take approximately 10-15 minutes.

Don’t worry, we’re good at keeping your secrets.

We take your privacy very seriously. Everything you tell us is confidential and protected securely in our system.

Part 1: Tell us about yourself (the basics).
Help us get to know a little bit about you.
Name*
First Last
Cell Phone*
Please include the 3 digit area code
Email*
When were you born?*
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Measured Body Weight (as of this AM)*
US Metric example: 150 lbs or 225 lbs
Height (US Metric)*
example: 5'5" or 5'8"
Part 2: What are your goals?
Everyone has their own reasons for working on their health and fitness. Tell us what you hope to get out of this experience.
How much would you like to lose weight? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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- 5
How much would you like to add muscle? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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- 5
How much would you like to look and feel better? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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How much would you like to learn how to stay consistent? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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How much would you like to gain more energy and vitality? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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How much would you like to get off medications? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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How much would you like to get control of your eating? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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How much would you like to learn how to maintain your weight, performance, and/or habits after achieving your goal? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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How much would you like to get stronger? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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How much would you like to improve your sport performance? (Rate importance from 1-5)*
1 = lowest priority, 5 = highest priority.
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If you had to choose between the following 4 goals, which one is most important to you?*
- Lose weight
- Gain muscle
- Improve health
- Support sport performance
Is there anything you'd like to add or elaborate on?*
Part 3: Tell us about your current nutrition and exercise habits.
What is your biggest nutritional challenge?*
Check all that apply.
- Cravings
- Don't know what I should eat
- Eating out frequently
- Eating quickly
- Emotional eating / stress eating
- Family / peer pressure
- Large portions
- Lack of planning
- Snacking when not hungry
- Sweet tooth
- Time to prepare meals
- Wine / alcohol
How many meals do you typically eat each day?*
This includes any shakes or snacks.
How many of your meals are prepared at home each day?*
How many meals do you eat out at cafeterias or restaurants each week?*
On an average day, how many ounces of water do you drink?*
For reference, 16 oz is a typical bottle of water & 128 oz in 1 gallon.
On an average day, how many of your meals include at least a palm-sized portion of protein (like meat, fish, dairy, eggs, or other protein dense plant foods)?*
On an average day, how many of your meals include at least one serving of colorful fruit or vegetables?*
On a scale of 1-10, how knowledgeable are you now about making smart food choices?*
1 = I know very little; 5 - I have some knowledge ; 10 = I'm a nutrition expert
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How many hours a week do you do some form of aerobic or cardio-type training?*
(e.g. jogging, brisk walking, cycling, boxing, fast swimming, etc.)
How many hours a week do you do some form of resistance training?*
(e.g. lifting weights, bodybuilding, powerlifting, strongman/woman, etc.)
How many hours a week do you do some form of intense conditioning or anaerobic interval-type work?*
(e.g. sprinting, Crossfit, wrestling, etc.)
How many hours a week do you do some form of low-intensity movement?*
(e.g. gentle walking, yoga, golf, Aquafit, etc.)
Dieting History
Tell us about your dieting history. Have you been restricting food intake/dieting in the last 12 months? (yo-yo dieter, binge eater, any disordered eating habits, diet hard and regain, never needed to diet till now, etc)
Describe your typical day from when you wake up to when you go to sleep:*
Do you have a regular menstrual cycle?*
- Yes
- No
Please explain why you don't have a regular menstrual cycle*
Are you on birth control? If yes, please list the kind. If not, type no.*
Have you ever competed before?
- Yes
- No
Have you ever used another coach or personal trainer?*
- Yes
- No
Tell us about your experience*
What do you feel worked well for you in the past and what do you feel needs to be corrected?*
Part 4: What's your work and family life like?
Lots of factors can affect our nutrition. This includes stress, social support, and time spent on work, family, and other responsibilities.
What's your favorite thing to do besides working out?*
Are you currently working?*
- Yes
- No
What do you do for a living?*
What time of day do you primarily work?*
Choose the answer that best applies.
- Mostly daytime hours
- Mostly nighttime hours
- I have a rotating schedule and do shift work
How many hours do you work on most days?*
Choose the answer that best applies.
- Fewer than 4 hours
- 4–6 hours
- 6-8 hours
- 8–10 hours
- 10–12 hours
- 12+ hours
What's your activity level at work?*
Choose the answer that best applies.
- Inactive; I'm mostly sitting
- Moderate; I'm on my feet for a part of every day
- Active; I'm moving all day
- Very active; I do physical labor
What is your typical stress level at work?*
Choose the answer that best applies.
- Low stress; my work is pretty relaxed
- Moderate stress; it's sometimes relaxed and sometimes crazy
- High stress; I'm always under pressure
What is your typical stress level at home?*
Choose the answer that best applies.
- Low stress; my work is pretty relaxed
- Moderate stress; it's sometimes relaxed and sometimes crazy
- High stress; I'm always under pressure
For all your lifestyle-related stressors, how well do you cope with stress?*
Choose the answer that best applies.
- Low stress; my work is pretty relaxed. My stress is pretty low and I do great when faced with most stressors.
- Although sometimes taxing, I have strategies for staying calm and focused.
- I sometimes feel on the brink of a breakdown and struggle with stress management.
Part 5: Digital photos and photo consent
About once a month, we recommend that you take simple front, side, and back photos of yourself in swimwear or other appropriate attire. This helps you literally see your progress, month to month.

Your privacy is very important to us. Only you and our 3 admins can see these photos.No one else can access or view your images.

Unless you give us permission to share your transformation...

If I have a fantastic transformation and The OMNI FIT feels my transformation could help inspire someone else, I consent to let them use the photos I provide. I understand that I will be notified in advance, and that I will be given the choice to have my face obscured in the photos to conceal my identity.

Note: It's completely fine to choose "no" here. However, we do periodically run body transformation contests with big prizes attached. To be eligible to win one of these contests, we require that you answer yes.
I consent to allow The OMNI FIT to use the photos I provide.*
- Yes
- No
Part 6: Medical release
Every individual who has regularly participated in and completed our coaching programs has become healthier and more fit.

But, we still need to be sure that you take full responsibility for your health and the monitoring of it.

It's important that you understand:
1. Our advice cannot — especially with distance-based coaching — replace the advice of a trained medical doctor.
2. It is your responsibility to work directly with your physician before, during, and after seeking coaching with The OMNI FIT or any other specialized consulting group.
3. If you choose to be coached by us without the prior consent of your physician, you agree to accept full responsibility for your decisions and to hold harmless The OMNI FIT, its agents, officers, and employers and any affiliated companies from any liability with respect to injury to you or your property arising out of or connected with your use of the information discussed.
Medical Release*
- I consent to this medical release.
- I do NOT consent to this medical release.
Please Select Your Coach*
This will send a copy of your answers to your coach
- Kala Duncan
- Jodie Vee
- Taylor Bloxham
- Not Assigned (Group Coaching or Event Attendee)
By selecting the "Submit" button, you are signing this Form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Form.

We want to get to know you.

Complete all the questions today.

Don’t worry, we’re good at keeping your secrets.

Part 1: Tell us about yourself (the basics).

Part 2: What are your goals?

Part 3: Tell us about your current nutrition and exercise habits.

Part 4: What's your work and family life like?

Part 5: Digital photos and photo consent

Part 6: Medical release