Personal Training Client Intake Form

Coaching Application

Work with me 1:1 - Whether you want to feel more confident, finally get that six pack or step on stage for the first time, I will create an individualized plan for you and your busy lifestyle. We will work together to achieve your goals. Fill out the form below to get started.
Part 1. Basic information
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Date of Birth

MonthDayYear
Age
years
Height
in
Weight
lbs
How did you find me?
Part 2. Lifestyle Information
What do you do for a living?
Whats the activity level at your job?
Do you follow a regular working schedule, do you work days, afternoon or nights?
Please list the physical activities that you participate in outside of the gym and outside of work
Part 3. Medical and Health Information
If you have any diagnosed health problems list the condition(s).
If you have any injuries, please list them.
Do you suffer from diabetes, asthma, high or low blood pressure?
Please list:
Do you have any diet restrictions?
Your current diet could be best characterized as:
Part 4. Goals
What following goals does best fit in with your goals?
Have you previously worked with another trainer/coach?
How often are you lifting weights right now? How long do you lift per session?
Do you lift one body part per workout session or do a full body work out? How many sets/reps do you do during your workouts? Do you use mostly machines or free weights?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

Please Read The Following Terms and Conditions
All the information on this form is accurate and correct to the best of my knowledge. I have sought out and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!
Should be Empty:

Coaching Application