Client Information and Intake Form
Assessment of Goals, Readiness, and Suitable Programming
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Male
Female
Email
*
example@example.com
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
What fitness goals do you have?
*
Muscle Gain
Weight Loss
Strength
Increased Endurance
Improved Flexibility
Increased Athletic Performance
What's motivated you towards the above selected goals?
By when do you want to achieve your goals?
*
E.g. a general timeline - ASAP, 3 months, 6 months, OR a specific date for an event - upcoming competition, wedding, etc.
How would you rate your current gym/exercise experience level?
*
Please Select
Beginner (just starting out)
Intermediate (been working out, just stuck right now)
Advanced (know what I'm doing, just need advanced programming)
How often do you currently exercise?
*
Please Select
I don't exercise at all yet,
1 - 2 times per week
3 - 4 times per week
5+ times per week
What exercise equipment do you currently have access to?
*
If you have access to a gym please give an idea of its level of equipment, e.g. hotel/apartment gym, commercial gym with all equipment, crossfit/powerlifting gym. If you are exercising at home list the equipment items you have.
What time of day do you normally exercise?
Please Select
4am - 8am
8am - 11am
11am - 2pm
2pm - 5pm
5pm - 10pm
Have you worked with a personal trainer before?
Please Select
Yes
No
If yes, what was your experience? Were your expectations met?
What are your expectations of your personal trainer now?
What do you find most difficult about sticking to a gym routine?
What does your current diet look like? (Do you feel like your nutrition supports your goals? Would you like to discuss a nutrition plan? etc.)
Are you willing to add natural supplements like creatine and a protein shake to your diet?
Please Select
Yes.
No, I don't know enough about those yet.
No, I'm not comfortable with that.
Describe a typical day in your life? (activity level, amount of sleep, stressors, amount of travel/free/time, hobbies, etc.)
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PAR-Q
Has your doctor ever said that you have a heart problem OR high blood pressure?
Please Select
Yes
No
Do you feel pain in your chest at rest, during your normal daily activities, or during physical activity/exercise?
Please Select
Yes
No
Do you lose balance because of dizziness OR have you lost consciousness in the last 6 months? (answer no if your dizziness was due to vigorous exercise or over-breathing)
Please Select
Yes
No
Have you ever been diagnosed with another chronic condition (other than heart disease and high blood pressure)? If yes, list below.
Are you currently taking prescribed medication for a chronic medical condition? If yes, list below.
Do you currently have, or have you had within the past 12 months, a bone, joint, or soft tissue (muscle, tendon, ligament) problem that could be made worse by becoming more physically active?
Please Select
Yes
No
If yes, give a description or list below.
Has your doctor ever said that you should only do medically supervised physical activity?
Please Select
Yes
No
Submit
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