Personal Trainer Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
FemaleMale
Height
in
Weight
lb
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
Do you have any injuries (past or present)? 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:

Your Information