Client Intake Form

CLIENT INTAKE FORM
Name

First Name Last Name
Date of Birth

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

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

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

Fat loss Build muscle Sport‐specific training Strength Shape and tone Reduce stress Weight loss Injury rehabilitation
How serious is your commitment to accomplishing these goals?

Kind of Moderate 100%!
What areas of your body do you specifically want to work on?
Is there a specific time frame in mind?
Training Experience:

Sedentary Beginner Upper‐Intermediate Upper‐Intermediate Advanced
Do you presently engage in physical activity?

Yes No
If yes, what kind and how often?
Are you currently participating in a structured resistance‐training program? *

Yes No
If yes, for how long?
Are you currently participating in a structured cardio‐respiratory program? *

Yes No
If yes, for how long?
How many days per week do you currently exercise?
What kind of cardio vascular activity do you enjoy most?

Elliptical Stair Climber Walking Stationary Bike Treadmill Running Stationary Rower Aerobics Class Other
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?? *

Yes No
Does your occupation require extended periods of repetitive movement? *

Yes No
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? *

Yes No
How many meals do you eat daily?
How many calories?
Do you eat meat? *

Yes No
What’s your favorite food:
Do you snack? *

Yes No
Favorite snack:
Do you have any dietary restrictions, food and/or allergies? *

Yes No
If yes, what?
Are you currently taking a multivitamin, mineral or other type of food supplement? *

Yes No
If yes, what?
Do you smoke? *

Yes No
Do you drink? *

Yes No
Do you drink more than 2 caffeinated beverages daily (coffee, tea, soft drinks)? *

Yes No
Are there any habits you would like to change? *

Yes No
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 problems Injuries to back, knees, ankles Brain concussion/head injury Loss of Consciousness Epilepsy High stress Chest pain of any kind Heart murmur High blood pressure Heart attack/stroke Heart rhythm abnormally Disease of arteries High cholesterol Varicose veins Lung disease Rheumatic Dizziness Problem with balance/vertigo Hypoglycemia Cancer Arthritis
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 attack High blood pressure Heart disease Heart operation High cholesterol Other
*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