New Client Intake Form

Your Information
Name

First NameLast NamePronouns
Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any diagnosed health problems?
Do you have any past or current injuries? If yes, please list below.
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What days work for your training?
What exercise equipment do you own or have access to? Gym membership, dumbbells, resistance bands etc.
What is your experience with breathwork?
What is your experience with movement/exercise?
What is your experience with mindfulness / meditation?
Which of the following statements fit in with your goals?

Other
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
What current challenges are you facing?
What is your ideal experience in working with a personal trainer?
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Did someone refer you?
Should be Empty:

Your Information