CLIENT ASSESSMENT FORM

CLIENT ASSESSMENT FORM
Name

First Name Last Name
Birth Date

MonthDay Year
Date
Phone Number
Email
example@example.com

Health & Lifestyle

	Yes	No	Occassionally
Do you smoke?
Have you had any surgery recently?
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?
Are you pregnant or planning to be?
Are you a type I or type II diabetic?

How often can you exercise per week?
How often do you currently exercise per week?
Please select the reasons you eat (besides hunger).

StressDepressionBoredomHappinessHabitAnnoyance
Please select the best days you can exercise.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please select the best times you can exercise.

Early MorningsMorningsEarly AfternoonsAfternoonsEveningsAnytimeDifferent daily, crazy schedule!
What are your goals for training?

Development of musclesReducing the stressLosing body fatIncreasing the motivationLifestyle change — longevityOther
Describe where you are at with your current health (sleep, stress, energy, eating patterns, etc).
Describe your goals of where you want your health to be.
What is your motivation for a lifestyle change?
What is your ideal “goal” weight? (This number isn’t everything! But a good basis)
Do you have any food allergies?
Do you take any medications? Do you have any diseases/health conditions?
Do you take any supplements?
How many meals do you eat a day and when? Give a quick sample below of what you eat in a day.
How many hours of sleep do you normally get? What time do you normally go to bed? Describe a typical nights sleep (if you work nights - describe a night at home and a night at work)
How much water do you roughly drink a day? How much coffee / tea / caffeine? How much alcohol do you drink per day and per week?
What type of physical activity do you do? How often? Be detailed!
How would you rate your stress on a scale of 1-10? Does anything you tried help reduce it?
Do you have a strong support system at home to help keep you motivated for this lifestyle change?
Anything else you want me to know? :)
Release and Acknowledgement
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 trainer 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.
Date

MonthDay Year
Date
Client Signature

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CLIENT ASSESSMENT FORM

Release and Acknowledgement