Fitness Client Intake Form

Health & Lifestyle*

Rows	Yes	No
Do you smoke?
Have you had any surgery in the last 2 years ?
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?

How would you rate your nutrition?*

0

1

2

3

4

5

0 is Poor, 5 is Excellent
Please describe your typical day of food. Include everything you eat and estimate amounts (for example use measuring units such as handful, cups etc). *
Be as specific as you can to establish a baseline.
Please select the reasons you eat (besides hunger).

StressDepressionBoredomHappinessHabitAnnoyance
List what type of exercise you absolutely dislike.*
List the type of exercise you enjoy.*
How often can you exercise per week?
Please select the best days you can exercise.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Why are you interested in coaching with me?*

Gain musclesReducing the stressLose body fatIncreasing the motivationTraining for an event/specific sportsGain confidenceFeel better about myselfOther
If you selected "Other" in the previous question please elaborate.
Release and Acknowledgement
I, {clientName}, at this moment, acknowledge that the information I've given above is complete and accurate. I understand all the risks and accept responsibility for any undesired situations during training. I am informed that the information in this form will be kept confidential.

If any of my health, lifestyle or personal information/situation that may prevent my training changes, I will inform my coach immediately.
Date

MonthDayYear
Date
Client Signature*

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Release and Acknowledgement