Personal Trainer Client Intake Form

Please fill in your Information
Name

First NameLast Name
Birth Date

MonthDayYear
FemaleMale
Height
cm
Weight
kg
Phone Number
Please enter a valid phone number.Format: (000) 0000000.
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? If yes, please list below.
Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
YesNo
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
MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Should be Empty:

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