CLIENT INTAKE FORM

Health & Lifestyle*

	Yes	No	Please fill in details
Do you smoke?
Do you have any injuries?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Have you worked with a coach before?

Do you eat throughout the night?

0

1

2

3

4

5

0 is Never, 5 is Always
Do you eat breakfast?

0

1

2

3

4

5

0 is Never, 5 is Always
What is your rate for your nutrition?

0

1

2

3

4

5

0 is Poor, 5 is Excellent
what does a full day of eating look like for you?
Please select the reasons you eat (besides hunger).

StressDepressionBoredomHappinessHabitAnnoyance
How often can you exercise per week?
Please select the best days you can exercise.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please select the best times you can exercise.

Early MorningsMorningsEarly AfternoonsAfternoonsEvenings
What are your goals for training?

Development of musclesReducing the stressLosing body fatIncreasing the motivationTraining for an event/specific sportsOther
If other please explain
Release and Acknowledgement
I, 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.

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.
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Client Intake Form