Fitness Client Intake Form
Client Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Please state if you have current/previous health diseases/issues.
Please state whether you take any medication.
Health & Lifestyle
Yes
No
Do you workout?
Do you lift?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Have you done sports professionally before?
Do you feel pain while doing sports/exercise?
At which frequency you eat at night?
0
1
2
3
4
5
Never
Always
0 is Never, 5 is Always
At which frequency you eat breakfast?
0
1
2
3
4
5
Never
Always
0 is Never, 5 is Always
What is your rate for your nutrition?
0
1
2
3
4
5
Poor
Excellent
0 is Poor, 5 is Excellent
How often can you exercise per week?
How many months will you do exercise?
Please select the reasons you eat (besides hunger).
Stress
Depression
Boredom
Happiness
Habit
Annoyance
Please select the best days you can exercise.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please select the best times you can exercise.
Early Mornings
Mornings
Early Afternoons
Afternoons
Evenings
What are your goals for training?
Development of muscles
Reducing the stress
Losing body fat
Increasing the motivation
Training for an event/specific sports
Other
Release and Acknowledgement
I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential. The fitness center has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I release and discharge the fitness center trainers, administration and workers from any disclosure of my personal information in this Fitness Client Intake Form. If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the fitness center authorities immediately.
Date
-
Month
-
Day
Year
Date
Client Signature
Submit
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