Personal Trainer Client Intake Form

New Client Intake Form

Candor Fitness LLC
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

FemaleMale
Height
Inches
Weight
lbs
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Are you taking any vitamins or supplements? If yes, please list below.
Do you have any injuries? If yes, please list below.
Do you know your blood pressure? If yes, what is your blood pressure?
How does your current diet look like?

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Do you smoke?

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
How often do you want to do personal training a week?

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

YesNo
Do you feel pain in your chest when you do physical activity?

YesNo
In the past month, have you had chest pain when you were not doing physical activity?

YesNo
Do you lose your balance because of dizziness or do you ever lose consciousness?

YesNo
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by change in your physical activity?

YesNo
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

YesNo
Medical History Present & Past HistoryHave you had or did you presently have any of the following conditions? (Check all that apply)

Rheumatic feverRecent operationEdema (swelling of ankles)High blood pressureInjury to back or kneesLow blood pressureSeizuresLung diseaseHeart AttackFainting or DizzinessDiabetesHigh cholesterolOrthopnea or paroxysmal ocurnal dyspneaShortness of breath at rest or with mild exertionChest painsPalpitations or tachycardiaIntermittent claudicant (calf cramping)Pain, discomfort in the chest, neck, jaw, arms, or other areasKnown heart murmurUnusual fatigue or shortness of breathe with usual activitiesTemporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or legOther
Family History Has any of your first-degree relative experienced the following conditions? (Check all that apply.)

Heart attackHeart operationCongential heart diseaseHigh blood pressure/high cholesterolDiabetesother major illness
Which of the following statements fit in with your goals? Check all that apply.

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
WAIVER OF CONSENT

In full consideration of the risk of injury while participating in the Activity, and for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily participate in this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any risks related to traveling to and from as well as participating the Activity, which may include, but are not limited to, physical or phycological injury, pain, suffering, illness disfigurement, temporary or permanent disability, economic or emotional loss, and death.

I acknowledge that I have carefully read this form and fully understand that it is a release of liability. I expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action. I also agree to voluntarily give up or waive any right I may otherwise have to bring legal action for personal injury or property damage.

I AGREE TO ALLOW CANDOR FITNESS LLC'S C MASTER PERSONAL TRAINER AND NUTRITIONAL CONSULTANT TO DESIGN A FITNESS PROGRAM FOR ME TO ENHANCE MY HEALTH & AND MY FITNESS GOALS. I WILL FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY. I WILL NOT HOLD CANDOR FITNESS LLC OR RELATED PERSONS OR PARTIES PERSONALLY LIABLE FOR ANY PROBLEMS, ILLNESSES, OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY EATING HABITS OR ACTIVITY LEVEL. I UNDERSTAND THAT CANDOR FITNESS IS NOT A REGISTERED OR LICENSED DIETITIAN NOR A MEDICAL PRACTITIONER. THIS FITNESS PROGRAM DOES NOT REPLACE THE EXPERT ADVICE OR MEDICAL TREATMENT OF A PRIVATE DOCTOR. I HAVE READ THIS ENTIRE DOCUMENT AND HAVE GIVEN CANDOR FITNESS LLC ALL NECESSARY AND HONEST INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS.
FURTHERMORE, I UNDERSTAND THAT ALL PURCHASED CANDOR FITNESS SERVICES EXPIRE 3 MONTHS AFTER PURCHASE. ALL SUBSCRIPTIONS REQURIE AN INITIAL SIX-MONTH COMMITMENT. AFTER SIX MONTHS, SUBSCRIPTIONS CAN BE CANCELED AT ANY TIME WITH A WRITTEN 30 DAYS NOTICE. ALL SESSIONS ARE SUBJECT TO BE CHARGED IF 24-HOUR NOTICE OF CANCELLATION IS NOT GIVEN.
I have read, understand and agree to the terms above.*
First Name Last Name Date Signature
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New Client Intake Form