Client Intake

Born 2 Dominate – Master Client Intake Form
This form collects the essential information we need to build a customised program for you under the Born 2 Dominate system.

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Section 1 - Personal Information
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Full Name (required)

Email Address (required)

Phone Number

Age (required)

Gender
MaleFemalePrefer not to sayOther

Country of Residence (required)

Occupation / Job Role

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Section 2 - Goals & Lifestyle
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What are your primary goals? (required)
Lose fatBuild muscleImprove healthImprove disciplineIncrease confidenceBuild a businessLearn tradingImprove communicationAll of the above

What are the top 3 outcomes you want in the next 90 days? (required)

How committed are you to achieving these goals? (required)
commitment "10 out of 10 I will do whatever it takes8 out of 10 I am ready but need structure" "6 out of 10 I need accountabilityBelow 6 Just exploring

What obstacles are holding you back right now? (required)

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Section 3 - Fitness & Training Background
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How long have you been training? (required)
[radio* training-duration "Never trained" "1-6 months" "6-12 months" "1-3 years" "3+ years"]

How many days per week can you consistently train? (required)
3 days4 days5 days6 days7 Days

Describe your current training routine (if any).

Any injuries or health conditions? (required)
YesNo

If yes, please describe.

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Section 4 - Nutrition & Dietary Info
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How would you describe your current eating habits? (required)
Very clean and consistentMostly healthyInconsistentPoorI do not track anything

Do you track calories or macros? (required)
Yes dailyYes sometimesNo but willing toNo not interested

How many meals do you typically eat per day?

What is your main nutrition goal? (required)
Fat lossMuscle gainImprove energyImprove performanceBetter overall healthAll of the above

Which foods do you struggle with?
SugarBread or pastriesChocolateFast foodSnacksFizzy drinksNone

Preferred diet style (if any):
High proteinLow carbBalancedVegetarianVeganPaleo or whole foodsMediterraneanNo preference

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Section 5 - Allergies & Intolerances
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Do you have any allergies or intolerances? (required)
YesNoNot Sure

If yes, list your allergies or intolerances.

Common allergens (tick all that apply):
NutsDairyLactoseGlutenEggsSoyShellfishFishWheatOther

Foods you absolutely hate.

Foods you absolutely love.

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Section 6 - Coaching Preferences
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What type of support do you want? (required)
One to one coachingGroup coachingOnline course onlyTraining programBusiness mentorshipTrading educationAll of the above

Preferred communication platform (required)
WhatsAppTelegramEmailZoom

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Section 7 - Readiness
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Are you ready to invest in yourself? (required)
YesMaybeNot yet

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Section 8 - Final Questions
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Why should we work with you? (required)

Do you agree to take responsibility, stay disciplined, and follow the program? (required)
YesNo

Type: I am ready to dominate. (required)