Client Intake Form

Do you have a heart condition or cardiovascular disorder?

Did the doctor advised you to limit physical activity and only perform the recommended activities by the professional?

Is there any chest pain when your doing any physical activity?

In the past month, did you experience any pain in the chest area when you're not doing anything?

Do you usually lose your balance due to being dizzy or even lose your consciousness?

Are you experiencing bone or joint problems that worsens if you change your physical activity?

Are you currently taking medications for your blood pressure or heart condition?

Is there any reason why you should not do physical activities?

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

If yes please list:

Is there any other medical injuries/history that you want to tell us about? Or anything that you think we should know about?

If you're answer is "NO" to all of the questions above, then you are safe to participate in physical activities. If you answer "YES" to one or more questions, then we need to have a further conversation about this to see what we can do.

Name

First NameLast Name

Gender

Age

Date of Birth

Date

Phone number

Please enter a valid phone number.Format: (07)000000000.

Email

example@example.com

Address

Street Address Line 1

Street Address Line 2 (optional)

TownCounty

Postal / Zip Code

Occupation

What is the activity level at your job?

Emergency Contact Person

First NameLast Name

Emergency Contact Person No.

Please enter a valid phone number.Format: (07)000000000.

Height (optional)

Weight (optional)

Do you have any previous experience in training/exercise?

What do you want to achieve? What are your goals? And why?

What following goals best suit you?

How often do you exercise currently?

How often are you willing to exercise?

Are you a current cigarette smoker?

Please rate your readiness for change:

Please rate your motivational level to do what it takes to reach your goal:

At what times during the day would you prefer to train?

I First name Last name herby affirm that I am voluntarily starting a course of instruction in physical fitness and performance training (The Activity). I am voluntarily participating in the Activity entirely at my own risk.
In full consideration of the risk of injury while participating in the Activity, and for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily participate in this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any kind of risks related to traveling to and from as well as participating the Activity, which may include, but are not limited to, physical or phycological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, economic or emotional loss, and death.
I acknowledge that I have carefully read this form and fully understand that it is a release liability. I expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action for personal injury or property damage.

Date

Signature

Client Intake Form

Personal Information

Personal Training consent form and liability waiver