Personal Trainer Client Intake Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Gender

Birth Date

MonthDayYear

Height

ft

Weight

lbs

Do you have any diagnosed health problems?

Are you taking any medications? If yes, please list below.

Do you have any injuries? If yes, please list below.

How does your current diet look?

Do you smoke?

What is your daily activity level?

1 is None, 5 is High

What is your daily stress level?

1 is Low, 5 is High

Which of the following statements best describes your goals?

What bodily areas are you looking to improve the most?

Please rate your readiness to change.

1 is Worst, 5 is Best

How did you hear about us?

Are you coachable and willing to apply yourself?

I, Name acknowledge that participation in the fitness and nutrition programs offered by Jaguar Athletics LLC possesses inherent risks, and hereby agree to assume all risks. I further relieve any employees or affiliates of Jaguar Athletics LLC from liability resulting in bodily injury, virus, any kind of contagious sickness or loss, whether personal belongings or bodily injury. I also hereby state that I am physically fit, and participate in the course of instruction by my own free will and with a clear conscience. Initials

Signature

Guest Registration