Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

FemaleMale
Height
cm
Weight
kg
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Do you have any injuries? If yes, please list below.
How does your current diet look like?

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
Do you smoke?

YesNo
What is your daily activity level?

1

2

3

4

5

1 is None, 5 is High
What is your daily stress level?

1

2

3

4

5

1 is Low, 5 is High
How often do you want to do personal training a week?

MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Which of the following statements fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
Should be Empty:

Your Information