Client Intake Form

Client Name

First NameLast Name

Birth Date

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Email

example@example.com

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Gender:

Weight in pounds:

Height in feet and inches:

What are your specific goals for your training program? Please rank them using the table below.

	Not Important	Somewhat Important	Important	Extremely Important
Improved Health
Improved Endurance
Increased Muscle Mass
Fat Loss/Weight Loss
Increased Strength
Increased Power
Weight Gain
Exercise Autonomy
Sport specific*

*If your goal is sport specific, please specify what sport or athletic event you are training for:

Is there a specific timeline for reaching your goal?

Where will you be training?

At HomeGymOther

If training at home, please list the equipment you have, including the weight of your resistance equipment:

Ideally, how many times per week would you like to engage in a fitness program?

Currently, how often are you engaging in physical activity?

0 times per week1-2 times per week3-5 times per week5-7 times per week

Please explain your current fitness routine if applicable. Include how long you engage in the activity and whether or not it is light, moderate, or vigrious activity.

Thinking about your current fitness routine (if applicable), what is/isn't working for you?

On a scale of 1-10 with 1 being barely alive and 10 being totally fit, how do you currently rate your physical fitness?

List up to 3 things you'd like to change about your physical fitness:

Occupation:

What is your activity level at your job?

Sedentary (sit at a desk all day)Moderate Activity (frequent walking throughout the day, some lifting)High Activity (physically demanding job with constant movement and very little sitting)

Does your job involve shift work?

YesNo

Please state if you have current/previous health diseases/orthopaedic issues that may affect your ability to complete physical activity:

If you are on any medications, please list them:

Are you currently undergoing any additional therapies or interventions for any of the above conditions (if applicable)?

Please indcate if you currently...

	Yes	No
Smoke Tobacco
Drink alcohol
Use recreational drugs

Please indicate in the space provided if you have a history of the following:

	Yes	No
Heart Attack
Bypass or cardiac surgery
Chest discomfort with exertion
High blood pressure (140/90)+
Rapid or runaway heartbeat
Skipped heartbeat
Rheumatic fever
Phlebitis or embolism
Shortness of breath with or without exercise
Fainting or light-headedness
Pulmonary disease or disorder
High blood fat (lipid) level
Stroke
Asthma
Diabetes
Epilepsy

Are you currently following a diet or meal plan?

YesNo

If you answered yes, what are you currently doing for your diet/meal plan?

Are you using any nutritional supplments or vitamins? If yes, please list them:

Do you have any allergies?

Do you require assistance with your diet or meal planning?

YesNo

Is there anything else you would like to share?

I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand that the information collected by Mallory Miller Fitness will be used for fitness evaluation purposess and for the design, implementation, progression, and maintenance of an individualized fitness program only.

I further understand that all such information is confidential and will not be shared with anyone without my prior written authorization, except in the case of a medical emergency or to the minimum extent necessary to achieve a safe and effective
fitness program.

By signing this form, I give my consent to participate in the physical fitness evaluation and training program conducted by Mallory Miller Fitness.

BENEFITS
Participation in a regular program of physical activity has been shown to produce positive changes in a number of organ systems. These changes include increased work capacity, improved cardiovascular efficiency, and increased muscular strength, flexibility, power and endurance.

RISKS
I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardiorespiratory system (dizziness, discomfort in breathing, heart attack). I hereby certify that I know of no medical problem (except those noted in this form) that would increase my risk of illness and injury as a result of participation in a regular exercise program.

TESTING AND EVALUATION RESULTS
I understand that I may undergo initial testing to determine my current physical fitness status. The testing will consist of completing this health inventory, taking a step test or bicycle ergometer test for cardiovascular fitness, and being tested for muscular fitness and body composition. I further understand that such screening is intended to provide Mallory Miller Fitness with essential information used in the development of individual fitness programs. I understand that my individual results will be made available only to me. I also understand that the testing is not intended to replace any other medical test or the services of my physician. I will be provided a copy of all test results. I may share the results with whomever I please, including my personal physician. By signing this consent form I understand that I am personally responsible for my actions during my tenure at/with Mallory Miller Fitness , and that I waive the responsibility of Mallory Miller Fitness if I should incur any injury as a result of my negligence.

Date

Client Signature

Client Intake Form

Release and Acknowledgement