Client Intake Form

  • CLIENT INTAKE FORM

  • Format: (000) 000-0000.
  • Gender

  • TRAINING GOALS

  • Primary Training and Nutrition Objectives (check all that apply)*
  • How serious is your commitment to accomplishing these goals?
  • Training Experience:
  • Do you presently engage in physical activity?
  • Are you currently participating in a structured resistance‐training program?*
  • Are you currently participating in a structured cardio‐respiratory program?*
  • What kind of cardio vascular activity do you enjoy most?

  • OCCUPATION

  • Does your occupation require extended periods of sitting??*
  • Does your occupation require extended periods of repetitive movement?*

  • HABITS

  • Have you ever suffered from insomnia?*
  • Do you eat meat?*
  • Do you snack?*
  • Do you have any dietary restrictions, food and/or allergies?*
  • Are you currently taking a multivitamin, mineral or other type of food supplement?*
  • Do you smoke?*
  • Do you drink?*
  • Do you drink more than 2 caffeinated beverages daily (coffee, tea, soft drinks)?*
  • Are there any habits you would like to change?*

  • 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.*
  • Have any of your blood relatives (brothers, sisters, parents, grandparents, aunts, uncles, etc.) had:*
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  • Should be Empty: