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.Format: (000) 000-0000.
Email
example@example.com
MaleFemaleOther
Body Weight, Body Fat %, Height
TRAINING GOALS
Fat lossBuild muscleSport‐specific trainingStrengthShape and toneReduce stressWeight lossInjury rehabilitation
Kind ofModerate100%!
What areas of your body do you specifically want to work on?
Is there a specific time frame in mind?
SedentaryBeginnerUpper‐IntermediateUpper‐IntermediateAdvanced
YesNo
If yes, what kind and how often?
YesNo
If yes, for how long?
YesNo
If yes, for how long?
How many days per week do you currently exercise?
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?
YesNo
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?
YesNo
How many meals do you eat daily?
How many calories?
YesNo
What’s your favorite food:
YesNo
Favorite snack:
YesNo
If yes, what?
YesNo
If yes, what?
YesNo
YesNo
YesNo
YesNo
HEALTH HISTORY
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?
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.*
Date
Should be Empty:

CLIENT INTAKE FORM