Personal Training New Client Form

Client Intake
Part 1. Basic information
Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age
years
Height
Weight
Part 2. Lifestyle Information
What do you do for a living?
What is the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work.:
Part 3. Medical and health information
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
if yes please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Part 4. Goals
What is your goal for training?
What following goals best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
Please rate your readiness for change.

12345678910
Why?

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

YesNo
If yes what kind of training did you do:
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
How often do you want to do Personal Training a week?
Please Choose
What are your expectations on me as your Personal Trainer?
Please Read The Following Terms and Conditions.
1.) CANCELLATIONS Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client. 2.) LATE ARRIVALS Sessions will not be extended (unless time is available and approved by the trainer) due to the lateness of the client or due to interruptions caused by the client. 3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
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I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Signature

Clear
Should be Empty:

Client Intake

Part 1. Basic information

Part 2. Lifestyle Information

Part 3. Medical and health information

Part 4. Goals

Please Read The Following Terms and Conditions.

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