Personal Training Client Intake Form

Personal Training Consultation Form
Part 1. Basic information
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Gender

MaleFemale
Age
years
Height
in
Weight
lbs
Part 2. Lifestyle Information
What do you do for a living?
Whats the activity level at your job?

None (seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?

RarelyA few times a yearA few times a monthWeekly
Please list the physical activities that you participate in outside of the gym and outside of work
Part 3. Medical and Health Information
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have current or past injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
Please list:
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
Part 4. Goals
Which of the following best describes your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Describe your goal more specifically.. Why?
How often are you willing to train per week to reach your goal?
Please rate your motivational level to do what it takes to reach your goal.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Have you trained with a personal trainer before?

YesNo
What kind of training did you do?
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEveningOther
How often do you want to work with a Personal Trainer per week?
Please Choose
What are your expectations on me as your Personal Trainer?
Please Read The Following Terms and Conditions
1.) CANCELLATIONS

Cancellations should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS

Yes

Personal Training Consultation Form

Part 1. Basic information

Part 2. Lifestyle Information

Part 3. Medical and Health Information

Part 4. Goals

Please Read The Following Terms and Conditions

Do you have any friends/family who could benefit from working with a personal trainer?