Personal Trainer Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
FemaleMale
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.
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
MondaysTuesdaysWednesdaysThursdaysFridays
Outside of personal training sessions, how often will you be training per week?
Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
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
Pay as you go - Bank Transfer - $120Pay as you go - Cash - $100Block booking 10 sessions - Bank Transfer - $1000
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