Client Intake Form

CLIENT INTAKE FORM
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender

MaleFemaleOther
Body Weight, Body Fat %, Height
TRAINING GOALS
Primary Training and Nutrition Objectives (check all that apply)*

Fat lossBuild muscleSport‐specific trainingStrengthShape and toneReduce stressWeight lossInjury rehabilitation
How serious is your commitment to accomplishing these goals?

Kind ofModerate100%!
What areas of your body do you specifically want to work on?
Is there a specific time frame in mind?
Training Experience:

SedentaryBeginnerUpper‐IntermediateUpper‐IntermediateAdvanced
Do you presently engage in physical activity?

YesNo
If yes, what kind and how often?
Are you currently participating in a structured resistance‐training program?*

YesNo
If yes, for how long?
Are you currently participating in a structured cardio‐respiratory program?*

YesNo
If yes, for how long?
How many days per week do you currently exercise?
What kind of cardio vascular activity do you enjoy most?

EllipticalStair ClimberWalkingStationary BikeTreadmill RunningStationary RowerAerobics ClassOther
Do you have an exact plan to obtain your goals?*
How long have you been thinking about starting a workout program?*
OCCUPATION
What is your current occupation?
Does your occupation require extended periods of sitting??*

YesNo
Does your occupation require extended periods of repetitive movement?*

YesNo
If you are a student, specifiy the subject you are studying.
How many hours do you work or go to school?
On a scale from 1 to 5, what is your stress level?*

1

2

3

4

5

1 is Low, 5 is High
HABITS
On average, how many hours of sleep do you per day?
Have you ever suffered from insomnia?*

YesNo
How many meals do you eat daily?
How many calories?
Do you eat meat?*

YesNo
What’s your favorite food:
Do you snack?*

YesNo
Favorite snack:
Do you have any dietary restrictions, food and/or allergies?*

YesNo
If yes, what?
Are you currently taking a multivitamin, mineral or other type of food supplement?*

YesNo
If yes, what?
Do you smoke?*

YesNo
Do you drink?*

YesNo
Do you drink more than 2 caffeinated beverages daily (coffee, tea, soft drinks)?*

YesNo
Are there any habits you would like to change?*

YesNo
HEALTH HISTORY
Please check, if applicable, any of the following health problems you have or have had that have been diagnosed or treated by a health professional.*

Orthopedic problemsInjuries to back, knees, anklesBrain concussion/head injuryLoss of ConsciousnessEpilepsyHigh stressChest pain of any kindHeart murmurHigh blood pressureHeart attack/strokeHeart rhythm abnormallyDisease of arteriesHigh cholesterolVaricose veinsLung diseaseRheumaticDizzinessProblem with balance/vertigoHypoglycemiaCancerArthritis
Arthritis, what kind?
Diabetes, how long ago?
Allergies, (hay fever/asthma) what kind?
Operations, what kind?
Old or recent injuries?
When was your last complete physical exam?
Who is your current physician?
Physician phone number.
If taking any medications, which one(s)?
Is there any good reason not mentioned here why you should not follow an activity program even if you wanted to?
Have any of your blood relatives (brothers, sisters, parents, grandparents, aunts, uncles, etc.) had:*

Heart attackHigh blood pressureHeart diseaseHeart operationHigh cholesterolOther
*I, the undersigned, have read, understand, and have answered the above health/medical survey question fully and truthfully, I am aware of my responsibility to consult with personal physician regarding my medical illness to engage in strenuous exercise and nutritional support program, I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the participating training facility, and the fitness trainer administering this instrument for any and all injuries suffered while following the training another nutrition program provided to me.*

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CLIENT INTAKE FORM