Personal Trainer Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

Other
Height
cm
Weight
kg
Phone Number

Area CodePhone Number
Email
example@example.com
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Do you have any injuries past or present? If yes, please list below.
Which of the following statements fit in with your goals?

Other

What is your daily activity level?

	1	2	3	4	5

1 is None, 5 is High

What is your daily stress level?

	1	2	3	4	5

1 is Low, 5 is High

Please rate your readiness to change.

	1	2	3	4	5

1 is Not ready, 5 is Let’s go!

Should be Empty: