Mackeyfit Intake Form for New Clients
Holistic Health Integration Profile and Consultation
Consultation counts as 1st session in any package.
Name__________________________ Home Phone: _________ Cell: __________
Address: ________________________________ Email: ________________________________
Preferred mode of communication for appointments and scheduling: email / phone / text message
Birthday: (m/d/y) _____________________ Exact time and place if known : _______________________
Outline of topics covered:
I. General Health and Fitness Questions
II. Health History
III. Athletic and Fitness Background &Experience
IV. Nutrition and Supplementation
V. Environmental Factors and Conditions
VI. Energetic Systems Assessment, including Aura and Chakras, Feelings, Emotions,
Consciousness
VII. Numerology
VIII. Astrological Profile
IX. Goals
X. Fitness Personality
XI. Feedback, Cuing, Individual Notes:
XII. Notes from general dialogue
XIII. Individualized & Suggested Reading and Materials List.
Please complete sections 1-10. 7 and 8 and 11-13 will be covered in person.
I General Health and Fitness Questions:
A. How do you currently feel? _________________________________________________
____________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. What does “healthy”, look and feel like to you?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C. What would it take for you to look and feel like you want to? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II. Health History
A. Family and Genetic health and predispositions? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. Beliefs about health and patterns? ___________________________________________________________________________________________________________________________________________________________________________________________________
C. Experienced any serious illnesses? ___________________________________________________________________________________________________________________________________________________________________________________________________
D. Overall attitude and general outlook on life? ___________________________________________________________________________________________________________________________________________________________________________________________________
E. Pain in any areas please list ___________________________________________________________________________________________________________________________________________________________________________________________________
F. Taking any medications? For? __________________________________________________________________________________________________________________________________________________________________________________________________
Other Notes:
III. Athletic and Fitness Background and Experience
A. What sports and activities have you participated in? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. Self efficacy within those sports and activities?__________________________________________________________________________________________________________________________
C. Duration, years played, time frame, skill level?______________________________________________________________________________________________________________________________________________________________________________________________
D. Exercise experience – free weights, machines, yoga, cardio? Other modes
of exercise?_____________________________________________________________________________________________________________________________________________________________________________________________
E. Which do you MOST enjoy?______________________________________________________________________________________________________________________________________________________________________________________________
F. What activities make you feel more energized?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
G. What activities make you feel relatively less energized or depleted?___________________________________________________________________________________________________________________________________________________________________________________________
H. Which make you feel strongest and most fit?_______________________________________________________________________________________________________________________________
I. Preferred exercise intensity and workout length?_____________________________________________________________________________________________________________________________________________________________________________________________
J. What kind of program do you currently follow if any….how is it structured?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
K. Have you had a trainer before? What was your experience? Likes/dislikes?
Preferences?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Notes:
IV. Nutrition and Supplements
A. Tell me everything that goes into your body….___________________________________________________________________________________________________________________________Typical
Breakfast:___________________________________________________________________________________________________________________________________________________________________________________________Lunch:_____________________________________________________________________________________________________________________________________________________________________________________________Dinner:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Snacks_____________________________________________________________________________________________________________________________________________________________________________________________
B. Eating habits; times of day, speed, portion sizes, food combinations?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C. Any dairy? What kinds/how much? __________________________________________________________________________________________________________________________________________________________________________________________________
D. What kinds of meat? How often and how much?______________________________________________________________________________________________________________________________________________________________________________________________
E. How much water do you drink? From what source?__________________________________________________________
F. Past habits, use of vitamins, minerals, supplements?_______________________________________________________________________________________________________________________
G. Any known vitamin/mineral deficiencies?________________________________________________________________________________________________________________________
H. Any emotional eating?____________________________________________________________________________________________________________________________
I. Digestion and assimilation ok?_________________________________________
J. Metabolic functioning? Rate?_____________________
K. Food allergies?_______________________________________________________
L. Blood Type: ________
Notes:
V. Environmental Factors and Conditions
A. Homeostatic and balanced living conditions?_________________________________________________________________________________________________________________________
B. Do you use air/water purifiers?________________________________________________
C. Hours of rest?_____________________________________
D. Feelings of balance or restlessness at home and work?
E. Stress? Please describe in detail your major stessors, if any, and how you
mange them. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
F. Relative point/time in life journey? Transition?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
G. Would you be interested in having a Astrology/Numerology/Archetype consultation
to get a clear view on your life path and position? __________________________________________________________________________________________________________________________________
VI. Energetic Systems Assessment, Including Chakras, Emotions, Sensitivities
(if answering these questions over email, I will go into more depth in person,
with this section.)
A. 1st Chakra -- are there any cultural, societal, familial, tribal beliefs that you notice effect you daily, positively or negatively? Are you grounded? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. 2nd Chakra -- What is your relationship to money, power, uniting with others?_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C. 3rd Chakra -- How do you feel about yourself? Honest with yourself? Trust
yourself? Feel courageous? Confident? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
D. 4th chakra --- lessons of forgiveness, love, emotions….how open is
your heart center? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
E. 5th chakra --- richest power comes from actions motivated by personal will
that trusts Divine Authority. Do you make wise and empowering choices for yourself
and others? Are your heart and mind congruent and communicating or blocked and
not working together? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
F. 6th chakra -- what is the quality of your symbolic perspective? Do you see
things clearly? Are you able to detach and see objectively the symbolic reasons
for why things happen, and put them into proper perspective that empowers, rather
than dis-empowers you?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
G. 7th chakra -- faith, spirituality, devotion, values, bigger picture, grace
bank account. What is your relationship to the divine? Can you follow inner
guidance when it is bestowed upon you?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VII. Numerology : ________________________ (will cover in person)
VIII. Astrological Profile :________________________________________ (will cover
in person)
IX. Goals
A. Primary ____________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. Short Term (1 to 3 months) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C. Mid range: (3 to 12 months) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
D. Long Range: (1 year and beyond)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Means to achieve these goals: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Process goals (not just outcome goals!): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
X. Fitness Personality ______________________________________________
A. Prefer to workout individually? With a partner? In larger group settings?
Classes?
B. Current level of motivation on a scale of 1 to 10? _____________________________
C. What is motivating you? Intrinsically or extrinsically motivated? ( By something
inside/outside of yourself?) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
XI. Feedback/Cueing/Individual Notes
XII. Notes from General Dialogue
XIII. Individualized and Selected Reading Materials Recommended