New Client Intake Form

New Client Intake Form
Client Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Please state if you have any current health diseases/issues.*
Please state whether you take any medication.*

Health & Lifestyle*

	Yes	No
Do you currently smoke?
Have you had any surgeries in the past year?
Do you currently drink alcohol?
Are you currently taking any vitamins or supplements?
Are you tracking your daily food intake?
Have you been professionally coached for sports/exercise before?
Do you feel pain while doing sports/exercise?

How often do you eat breakfast?

0

1

2

3

4

5

0 is Never, 5 is Always
How often do you eat/snack after 7pm?

0

1

2

3

4

5

0 is Never, 5 is Always
How would you rate your current dietary habits?

0

1

2

3

4

5

0 is Poor, 5 is Excellent
How many days per week are you committed to exercising?*
What is the timeline to achieve your goals?*

8 weeks10 weeksMore than 10 weeksHowever long it takes to achieve my desired results
Please select the reasons you eat (besides hunger).*

StressDepressionBoredomHappinessHabitAnnoyance
Please select the best days you can exercise*

MondayTuesdayThursdayFridays
Please select the best time of day you would like to exercise.*

Early Mornings (5am-8am)Late Morning/Afternoon (9am-12 noon)Evenings (4pm-6pm)
What are your goals for training?*

Build MuscleReduce StressLose Body FatIncrease MotivationDevelop a routine/consistencyTrain for an event/specific sport
A consultation is required prior to purchasing training sessions. This is a face-to-face meeting with Dasia Grady to discuss clients' fitness goals and training expectations. The client will be given the opportunity to ask questions pertaining to their health and fitness goals. During the consultation, the client will be taken through a FULL-BODY FITNESS ASSESSMENT to gauge current level of fitness and to obtain information that will be used to create a custom workout program.

Please use the calendar below to book your consultation.
Release and Acknowledgement

***PLEASE READ***
I, hereby acknowledge that the information I've given above is complete and accurate. I understand that all information in this form will be kept confidential. If any of my health, lifestyle or personal information changes, I agree to inform Dasia Grady immediately.

Program Objectives and Procedures:

I understand that the personal training program may include exercises to enhance the clients cardiorespiratory system (heart and lungs), musculoskeletal system, (which involves muscular endurance, strength, and overall flexibility), and to improve body composition (increasing muscle and decreasing body fat). Exercises could include but are not limited to aerobic activities, such as walking, running, bicycle riding, rowing machine, aerobics, swimming, weight lifting, using dumbbells, machines, and other equipment to improve muscular strength and cardiovascular endurance, as well as flexibility exercises to improve joint range of motion.

Medical Disclaimer:

Dasia Grady is not a licensed medical care provider or registered dietician and has no expertise in diagnosing, examining, or treating medical conditions of any kind. Dasia Grady strongly recommends that you consult with your physician before beginning any exercise program. You should be in good physical condition and able to perform the exercises in your training program. If you engage in this exercise or exercise program, you agree that you do so at your own risk, and are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge the private training facility and Dasia Grady from any and all claims or causes of action, known or unknown.

Personal Disclaimer:

Dasia Grady is a Certified Personal Trainer and Nutrition Coach through the National Academy of Sports Medicine. The information provided is based on personal experience, and studies as a NASM Certified Personal Trainer, and Nutrition Coach. Any recommendations provided should be revised by a doctor before starting.
Date Submitted

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Consultation Deposit This is a $50 one-time payment that solidifies your appointment. Deposit goes toward the OVERALL COST of the training package you choose. If no training sessions are purchased, DEPOSIT IS NON-REFUNDABLE. Address given after purchase. Located in Elk Grove, CA. You will receive a text from Dasia Grady with all the information you need prior to your consultation.
$50.00

Total

$0.00
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New Client Intake Form

Release and Acknowledgement