Fitness Assessment Form
Client Intake Application
(Be as detailed as possible)
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Health-Related Questions
Are you currently taking any exercise program?
Yes
No
Height (in)
Weight (lbs)
Do you have the following conditions?
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Hypertension
Glaucoma
Bone problems
Respiratory issues
Migraine
Other
Are you a smoker?
Yes
No
Are you pregnant? (female only)
Yes
No
Do you drink alcohol?
Yes
No
How many times do you exercise in a day?
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
Yes
No
What do you usually eat in breakfast?
What do you usually eat in lunch?
What do you usually eat in dinner?
How much water do you drink daily? How much rest do you get daily?
Are you currently taking medications? If yes, what are the medications and for what purpose?
Have you had any bodily injuries or been previously hospitalized ? If yes, please indicate when and why.
Did you undergo any surgeries in the past? If yes, please indicate the type of surgery.
What are your goals in this program?
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
Compete in Bodybuilding Competition
Pregnancy/ Postpartum
How much time in a week can you dedicate to this program? Tell me about your goals and when you would like to start. (Be specific)
Are you interested in going to the gym or working out from home?
Please Select
Going to the gym
I’ll be working out at home
Start off at home then eventually go to the gym
Client Signature
Date Signed
-
Month
-
Day
Year
Date
Print Form
Submit
Submit
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