Client Intake Form for Ageless Method

Client Intake Form for Ageless Method
Let's get to know each other a little better! I'm Ash Walton Massey, and I have been in the fitness industry since 2013. I am a certified personal trainer and certified Pilates Mat and Reformer instructor. My favorite exercises are:
- Pilates Mat,
- Pilates Reformer,
- Strength training,
- Dance
- Kickboxing
I have trained clients at various fitness levels with long-term fitness goals. My background is in healthcare, so I have been able to help many clients recovering from injuries and procedures.

The motto for Ageless Method is: Ageless Wonder, Ageless Living. Exercise and other healthy habits allow us to turn back the clock. The healthy decisions we make today can lead to a beautiful future!

Now tell me more about you!
Client Name

First NameLast Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Please state if you have current/previous health diseases/issues.
Please state whether you take any medication.

Health & Lifestyle

	Yes	No
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?

What is your rate for your nutrition?

	0	1	2	3	4	5

0 is Poor, 5 is Excellent

How often can you exercise per week?
How many months will you do exercise?
Please provide days and times you would prefer to train.
What are your goals for training?

Development of musclesReducing the stressLosing body fatIncreasing the motivationTraining for an event/specific sportsOther
What is your motivation for training?
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.

Ageless Method 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 Ageless Method from disclosure of my personal information in this Client Intake Form.

During my time training with Ageless Method, I will attend training sessions in which I will be shown and instructed in how to improve my physical fitness. I acknowledge that it is my responsibility to make healthy choices outside of my training sessions to achieve maximum results. If I am unable to maintain a consistent schedule with sessions, I understand my progress may be affected. So, I will be prepared to train at the fitness level that my trainer deems appropriate for my current state.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform Ageless Method immediately.
Date

MonthDayYear
Date
Client Signature

Powered by Jotform SignClear
Should be Empty:

Client Intake Form for Ageless Method

Release and Acknowledgement