BjorkFitness Clients Intake Form

BjorkFitness Clients Intake Form
Client Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please state if you have current/previous health diseases/issues.*
Please state any and all medication.*

Health & Lifestyle*

	Yes	No
Do you smoke?
Have you had any surgeries?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Do you feel pain while doing exercises?

If you answered "Yes" in any above, please explain in more detail.
At which frequency do you eat at night?*

0

1

2

3

4

5

0 is Never, 5 is Always
At which frequency do you eat breakfast?*

0

1

2

3

4

5

0 is Never, 5 is Always
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?*
Please select the reasons you eat (besides hunger).*

StressDepressionBoredomHappinessHabitAnnoyance
Please select the best days you can exercise.*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please select the best times you can exercise.*

Early MorningsMorningsEarly AfternoonsAfternoonsEvenings
What are your goals for training?*

Development of musclesReducing the stressLosing body fatIncreasing the motivationTraining for an event/specific sportsOther
Any additional info:
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.

Sasa Bjork 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 Sasa Bjork from any disclosure of my personal information in this Online Fitness Client Intake Form.

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

MonthDayYear
Date
Client Signature*

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BjorkFitness Clients Intake Form

Release and Acknowledgement