Client Intake Form

Client Name*

First NameLast Name

Birth Date*

Date

Phone Number*

Email*

example@example.com

What are you looking to get out of this coaching?*

Overall, how do you feel about your existing exercise routines and your current level of activity?

0 is Poor, 5 is Excellent

How would you rate your satisfaction with your current nutritional habits and how they support your physical activity?

0 is Not satisfied, 5 is Satisfied

How would you rate your satisfaction with your current sleep habits and how they support your physical activity?

0 is Not satisfied, 5 is Satisfied

Please detail your typical types of physical activity within a week, noting how often you do them. *If it varies a lot from week to week (which is normal) talk a little about why.*

(e.g. Walks, yoga, stretches, runs, sports, activities, gym workouts, home workouts etc.)

Upload any workout routine documents here.

Please share your thoughts on your current nutrition habits. Let me know what aspects of your diet you enjoy or find effective, and any areas you would like to change or improve.

Please share any initial thoughts, goals, feelings or desired changes related to the following areas of fitness. If an area doesn't apply to you or your goals, please write N/A.

Where do you plan to work out during the program? Check all the places that apply to you:

About how many days per week do you have to dedicate to the workout routine that will be provided? What time do you prefer to workout and for about how long?

Would you be interested in learning more about the psychology behind habit/behaviour change?

YesNo

Are you comfortable discussing your menstrual cycle? If yes, would you be interested in factoring your cycle into your monthly workout planning? (Feel free to skip this question.)

Are there any imbalances, tendencies or past injuries that should be factored into the exercises chosen for your program?

Are there specific movements you avoid due to pain? Or are there specific movements you incorporate into your workouts to avoid pain?

Are you currently engaged in any prescribed physiotherapy exercises? If yes, how often do you currently perform these exercises? How frequently would you ideally like to perform these exercises?

Please describe any physiotherapy routines you currently engage in, or are recommended to perform. (You may also upload any screenshots or documents below)

File Upload

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.

The fitness center 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 the fitness center trainers, administration and workers from any disclosure of my personal information in this Fitness Client Intake Form.

Additionally, I acknowledge that this program is not a substitute for professional physiotherapy. I will be provided with exercises and cues with the understanding that I know how to manage my body and any existing injuries. Should I feel unsure about safely performing any movement, it is my responsibility to consult a qualified kinesiologist or physiotherapist. Additionally, if I experience pain that has not been evaluated by a medical professional, I will seek advice from a qualified healthcare provider before starting any new fitness program.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the fitness center authorities immediately.

Date

Client Signature

Client Intake Form

Current Overview

Goals & Direction

Body Mechanics

Release and Acknowledgement