Personal Trainer Client Intake and Liability Form

  • Bronco Fitness & Performance

  • Client Consultation Form

  • Gender*

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  • What is the best way to contact you?*

  • Lifestyle Information

  • PAR-Q

  • Have you been diagnosed by a doctor with a heart condition?*
  • Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?*
  • Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*
  • Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*
  • Are you currently taking prescribed medications for a chronic medical condition?*
  • Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?*
  • Has your doctor ever said you should only do medically supervised physical activity*

  • Health and Medical

  • Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason?*
  • Has anyone of your immediate family developed heart disease before the age of 60?*
  • Do any diseases run in your family?*
  • Do you suffer from or have a history of:*

  • Are you a current cigarette smoker?*
  • Do you drink caffeinated drinks?*
  • Do you drink alcohol?*
  • Do you have any pain or issues in your:*

  • Are you on any specific food/diet plan at this time?*
  • Have you had any recent weight gain or loss?*
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  • Is there any reason not mentioned why you should not follow a regular exercise program? (Please remember it is your responsibility to you to consult with a physician before starting an exercise routine)*

  • Goals

  • Which of the following goals best fit in with your goals for your training (select all that apply)?*

  • What possible personal barriers do you feel are keeping you from reaching your nutritional and fitness goals?*

  • Training and Exercise History

  • Do you have a membership at a commercial gym?*
  • What equipment do you have access to at home?

  • Do you currently exercise on a regular basis?*
  • Do you currently participate in any competitive sports?*
  • Have you trained with a Coach before?*

  • Personality

  • What motivates you?

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