Personal Trainer Client Intake Form

BODYWISE COACHING

Consultation Form
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Height
cm
Weight
kg
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What do you do for a living?
How many steps on average do you do in a day?
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.
Do you have asthma, diabetes, high or low blood pressure?
Do you smoke?
How does your current diet look like?
Would you like nutritional guidance to help you progress?
Please rate your readiness to change.

1

2

3

4

5

1 is Worst, 5 is Best
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 would you rate your experience in the gym?

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2

3

4

5

1 is Worst, 5 is Best
How often do you want to do personal training a week?
Which of the following statements fit in with your goals?

Other
Are there any specific exercises you enjoy / do not enjoy?
Do you have anything you would like to achieve? This could be things such as run a specific distance, amount of weight loss / gain, or even being fit enough to climb a mountain!
How motivated are you to reach your goals?

1

2

3

4

5

1 is Worst, 5 is Best
What are you expectations on me as your trainer?
I AGREE TO THE TERMS & CONDITIONS ABOVE
Signature
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BODYWISE COACHING