Personal Trainer Client Intake and Liability Form

Love It Fitness

PAR-Q and Lifestyle Form
Client Intake Form
Full Name*

First NameLast Name
Age*
years
Height*
Inches
Weight*
lb
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Email*

Confirmation Emailexample@example.com
Lifestyle Information
What do you do for a living?*
none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)

How would you rate the stress of your job?*

	1	2	3	4	5	6	7	8	9	10

1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown

How would you rate the stress of your lifestyle?*

	1	2	3	4	5	6	7	8	9	10

1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown

What are your hobbies, or what do you like to do in your spare time?*
PAR-Q
yesno
yesno
yesno
yesno
If yes to the above question, please list the condition(s) here.
yesno
If yes to the previous question, please list your medications and how long you have been taking them.
yesno
If yes to the above question, please explain the condition.
yesno
Health and Medical
YesNo
If Yes to the question above, please list reason here.
If you are on any medications not previously mentioned, including multivitamins,please list them here, including how long you have been taking them. Enter none if none.*
If you have any diagnosed health problems not previously mentioned, please list the condition(s) here. Enter none if none.*
Please list any injuries or surgeries you have had in the past five years. Enter none if none.*
YesNo
YesNo
If yes to the above question, please explain.
Diabetes Type 1Diabetes Type 2AsthmaHigh blood pressureLow blood pressureHeart attackBypass or cardiac surgeryChest discomfort with exertionRapid or runaway heartbeatSkipped heartbeatShortness of breath with or without exerciseFainting or light-headednessPulmonary disease or disorderStrokeHigh cholesterolRecent hospitalizationsOrthopedic problems, including arthritisOther
If yes to any of the above, please explain here.
YesNo
If yes, how many cigarettes or ecigs per day?
YesNo
If yes, what and how many per day?
If yes, how many glasses per day?
Head/NeckUpper BackShouldersArm/ElbowWrist/HandsLower BackHips/PelvisThigh/KneesHerniaOther
If yes, please explain.
YesNo
If yes, please explain.
YesNo
If yes, please explain:
Please list any dietary supplements you take here (protein powder, creatine, B12, etc). Enter none if none.*
YesNo
If yes, please explain:
Goals
Appearance/AestheticsCardiovascular EnduranceFlexibilityHealth (General)Muscular DefinitionMuscular SizeMuscular Strength/PowerSelf-esteem/ConfidenceSpeedSports PerformanceStress ReductionWeight LossPostureOther
Lack of motivationTimeSelf ConsciousLack of equipmentLack of ResultsHitting A PlateauMoneyNot knowing where/how to beginOther
How often are you willing to train per week to reach goals?*
Training and Exercise History
YesNo
If yes, what gym?
DumbbellsBarbellsWeight BenchAerobic Machines (treadmill, elliptical, stationary bike, rower, etc)Weight MachinesCable WeightsResistance BandsBosu BallKettlebellsSuspension StrapsPunching BagStability BallPilates ReformerOther
YesNo
If yes, how many days a week?
How long is each session in minutes?
YesNo
If yes, what sports and how often?
YesNo
If yes, was your previous experience negative or positive? Why?
Mental Readiness/Personality
Need a strong motivator to push you to exerciseYou like to be informed about your program and how it is going to lead you to your goalsLike to try new things if they are effectiveWilling to push past your comfort level to reach your goalsIf I feel things are really hard I tend to back offNeed to be held accountable for what I am doingBeing sore the day after a workout tells me my workouts are workingOther
Today's Date*

MonthDayYear
Date
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Love It Fitness

Client Intake Form

Lifestyle Information

PAR-Q

Health and Medical

Goals

Training and Exercise History

Mental Readiness/Personality