Personal Training Intake Form

Name

First NameLast Name

Date of Birth

Date

Sex

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

E-mail

Occupation

Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship

Primary Care Physician

First NameLast Name

Physician's Phone Number

Area CodePhone Number

Height (feet):

Weight (lbs):

Existing Medical Conditions: Please check the appropriate conditions.

Please list any medications you take.

Please indicate if you have pain or have any history of injury.

Please indicate any history of surgery.

How many days is your ideal gym program?

Are there any machines or exercises you enjoy performing? Are there any exercises you dislike?

Will you be performing any physical activity outside the gym?

How active is your job?

Please indicate if the following statements are always, sometimes, or rarely true.

	Always	Sometimes	Rarely
I get seven to eight hours of sleep per night.
I am physically active three times a week.
I have regular medical checkups.
eat three to five servings of vegetables daily.
I eat two to four servings of fruit daily.
I make a conscious effort to eat healthy.
I follow a strict diet.
I have no stress in my life.
I am highly motivated.
I am a very happy person.

What are your current health and fitness goals?

What are your biggest struggles when it comes to reaching your goals?

On a scale of 1-5, please rate your commitment to reaching your goals:

	1	2	3	4	5

1 is Not committed at all, 5 is Very committed

Kristen Lillie needs your informed consent to provide fitness assessment and personal training services to you and to collect and use your personal information. We want you to understand the services we provide and what we may do with your personal information.
I, the undersigned, do hereby acknowledge:

My consent to perform an exercise program designed by my personal training specialist
I understand the content of the exercise program will be based on testing results and direct consultation with a personal training specialist
My understanding that exercises will consist of one or more of the following components: cardiovascular aerobic exercise; muscular strength and endurance; balance training; and flexibility;
My understanding that there are potential risks, i.e. episodes of transient lightheadedness or possibly loss of consciousness, and I assume willfully these risks;
My obligation to immediately inform the fitness of any abnormal symptom that I may suffer during and immediately after the testing;
My understanding that I may stop or delay any exercise if I so desire and that the training session may be terminated by the personal training specialist upon observation of any symptoms of undue distress or abnormal response;
My understanding that I may ask any questions or request further explanation or information about the procedures at any time before, during and after the training;
That I have read, understood, and completed the medical screening questionnaire (PAR-Q) and obtained medical clearance if necessary;
That I hereby release Kristen Lillie, from any liability with respect to any damage or injury (including death) that I may suffer during the administration of the appraisal except where damage or injury is caused by the negligence of Kristen Lillie, acting within the scope of her duty.

Name & signature of patient/legally responsible person

Reason why patient is unable to sign

Date Signed

Date

Personal Training Intake Form

Personal Information

Emergency Contact

Medical History

Activity Preferences

Lifestyle

Assumption of Risk and Waiver of Liability