1:1 LIfestyle Coaching

New 1:1 Lifestyle Coaching Intake Form

Please fill out this form to help us understand your needs and preferences for personalized coaching.
Full Name*

First NameLast Name
Phone Number
Email*
Age*
Minimum age is 18
Height*
Current Weight*
What type of fitness tracker do you currently use. If none, put none.*
YesNo
If yes, explain your previous sport experience.
Current Lifestyle
What do you do for work?*
None (seditary)Moderate (light activity, such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoons or nights?*
Rarelya few times a yearA few times a monthWeekly
What type of movement or exercise are you currently doing?(Please list activities such as walking, strength training, yoga, etc.)*
YesNo
About how many steps do you currently do daily?*
YesNo
If yes, explain your experience and why did you stop. Why are you looking to work with a trainer now?*
Nutrition
How many ounces of water do you currently drink*
Do you have any known allergies, sensitivities, or chronic health conditions*
Do you have experience tracking your food?*
MacrosCaloriesMeal PlanI have never tracked my food, so im not sure
YesNo
YesNo
None1-2 alcoholic beverages per week5-10 alcoholic beverages per weekMore than 10 alcoholic beverages a week
Medical & Health Information
Are you currently taking any supplements, vitamins, or medications?(Please list name and frequency if known)*
List any current injuries*
How would you describe your current energy levels throughout the day?*
How would you describe your hormone health or menstrual cycle right now?(e.g., regular, irregular, on birth control, menopausal, currently working with a doctor, etc.)*
Mindset & Goals
What motivates you most and how would you describe your mindset when it comes to making changes?(e.g., all-or-nothing, balanced, routine-driven, need accountability, etc.)*
Stress ManagementNutrition and DietPhysical FitnessSleep ImprovementMindfulness and MeditationWeight ManagementOther
If you selected 'Other' for Areas of Focus, please specify.
What motivates you most and how would you describe your mindset when it comes to making changes?(e.g., all-or-nothing, balanced, routine-driven, need accountability, etc.)*
Do you have anyone supporting or encouraging you in your health and lifestyle goals right now?(e.g., friends, family, partner, community, or none currently)*
Lifestyle Coaching Liability Waiver
Client Liability Waiver & Informed Consent

I understand that the coaching services provided by Eterna Wellness Coaching are intended for general lifestyle, fitness, and wellness education purposes. I acknowledge that these services are not medical advice and that my coach is not a licensed medical provider, nutritionist, or therapist.

I understand that I should consult with my physician before beginning any new exercise, nutrition, or wellness program — especially if I have any existing medical conditions, injuries, or concerns.

I recognize that participation in exercise, nutrition, and lifestyle programs involves inherent risks, including but not limited to physical injury, illness, or unforeseen reactions. I voluntarily assume all responsibility for my participation and any risks associated with it.

I hereby release and hold harmless Eterna Wellness Coaching, its owner, coaches, employees, contractors, and affiliates from any and all liability, claims, demands, or causes of action arising out of or connected with my participation in coaching services or related activities.

I acknowledge that results are not guaranteed, and progress depends on my consistency, effort, and adherence to recommendations.

By signing below, I confirm that I have read and fully understand this waiver, and that I am participating voluntarily.
I agree
Photo & Video Release Waiver
Media Release Authorization

I, the undersigned, hereby grant permission to Eterna Wellness Coaching and its representatives to capture my image, voice, likeness, or performance in photographs, videos, or other media during coaching sessions, events, or other related activities.

I understand that these materials may be used for educational, marketing, or promotional purposes, including but not limited to social media, websites, or print materials.

Client Approval Clause
I acknowledge that no photo, video, or testimonial will be published, posted, or shared publicly without my prior written or verbal approval. I will be given the opportunity to review any content before it is used.

Confidentiality
I understand that my privacy and personal information will be respected and that any media used will not include sensitive health or personal details unless explicitly approved by me.

Release of Liability
I release Eterna Wellness Coaching, its employees, contractors, and representatives from any claims, damages, or liability that may arise from the use of such media, provided all use follows the approval conditions stated above.
I agree
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New 1:1 Lifestyle Coaching Intake Form

Current Lifestyle

Nutrition

Medical & Health Information

Mindset & Goals

Lifestyle Coaching Liability WaiverClient Liability Waiver & Informed Consent

Photo & Video Release WaiverMedia Release Authorization

Lifestyle Coaching Liability Waiver
Client Liability Waiver & Informed Consent

Photo & Video Release Waiver
Media Release Authorization