Personal Trainer Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Height
cm
Weight
kg
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? If yes, please list below.
How does your current diet look like?
Do you smoke?
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?
Outside of personal training sessions, how often will you be training per week?
Which of the following statements fit in with your goals?

Other
Elaborating on the above. What are your goals?
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
PT Package - Please select option
I confirm that all the above is correct.
I confirm that I am to provide a minimum of 12 hours notice when unable to attend a session to avoid being charged.
Signature
Should be Empty:

Your Information