Client Intake Form

1
Client Name
First Name
Last Name
2
Zip code
3
Birth Date
Date
Month
Day
Year
4
Phone Number
Area Code
Phone Number
5
Email
example@example.com
6
Instagram
@example
7
Emergency Contact Name
First Name
Last Name
8
Emergency Contact Phone Number
Area Code
Phone Number
9
What is your height?
10
What is your weight?
11
Please state if you have current/previous health diseases/issues.
12
Please state whether you take any medication.
13
Health & Lifestyle
Yes
No
Do you smoke?
Row 0, Column 0
Row 0, Column 1
Have you had any surgery since one year?
Row 1, Column 0
Row 1, Column 1
Do you drink alcohol?
Row 2, Column 0
Row 2, Column 1
Are you using any additional vitamin or supplements?
Row 3, Column 0
Row 3, Column 1
Are you tracking your daily food intake?
Row 4, Column 0
Row 4, Column 1
Have you done sports professionally before?
Row 5, Column 0
Row 5, Column 1
Do you feel pain while doing sports/exercise?
Row 6, Column 0
Row 6, Column 1
Do you smoke?
Have you had any surgery since one year?
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?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
1 of 7
14
What do you do for a living?
15
How many times per week do you currently exercise?
None
1-2
3-4
5<
16
Describe your fitness progress thus far
Poor ( little to no progress)
Struggling (some progress, but not fast enough)
Successful ( Nice progress, but looking for more improvement)
17
If you could start making real results toward your fitness goals, will you comply with my recommendations?
Yes
No
18
Have you trained with a personal trainer before?
Yes
No
19
What is your biggest struggle or challenge when it comes to fitness and working out?
20
List all minor and major injuries that may limit your ability to exercise:
21
Do you currently have any health conditions that we should know about (please include those that may interfere with exercise or nutrition ( such as asthma, high or low blood pressure, etc.)
22
At which frequency you eat at night?
0
1
2
3
4
5
Never
Always
23
At which frequency you eat breakfast?
0
1
2
3
4
5
Never
Always
24
What is your rate for your nutrition?
0
1
2
3
4
5
Poor
Excellent
25
Are you interested in a meal plan? Do you have any dietary restrictions?
26
How often can you exercise per week?
27
Do you have a gym membership? Please provide name and location
28
How many months will you do exercise?
29
Please select the reasons you eat (besides hunger).
Stress
Depression
Boredom
Happiness
Habit
Annoyance
30
Please select the best days you can exercise.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
31
Please select the best times you can exercise.
Early Mornings
Mornings
Early Afternoons
Afternoons
Evenings
32
What are your goals for training?
Develop muscles
Reduce the stress
Lose body fat
Increase motivation
Train for an event/specific sports
Other
33
How did you discover Khulture Fitness?
Social media ( Instagram, YouTube, Facebook, Twitter)
Through a friend or family
Ad
Other
34
How do you typically learn about health and fitness?
35
Is there anything else you would like to share?
36
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.
37
Date
Date
Month
Day
Year
38
Client Signature
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