Client Intake Form

Client Name

First NameLast Name

Birth Date

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Your Height

Your Current Weight (IBS)

Instagram or Facebook Username

Have you worked with a coach before?

What is your level of knowledge of physical activity and movements?

What is your biggest struggle?

What is your no. 1 fitness goal right now?

Health & Lifestyle

Rows	Yes	No
Do you smoke?
Have you had any surgery's in the last year?
Do you drink alcohol?
Are you using any additional vitamins or supplements?
Are you tracking your daily food intake?
Do you feel pain while doing sports/exercise?

How often can you exercise per week?

Please select the best days you can exercise.

Please select the best times you can exercise.

On a scale of 1-5, how committed are you?

Are you financially ready to invest into yourself?

If accepted, are you ready to start in the next 7 days?

I, {clientName}, 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.

Kaden J. Floyd has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I release and discharge this information to Kaden J. Floyd from any disclosure of my personal information in this Fitness Client Intake Form.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform Kaden J. Floyd immediately.

Date

Client Signature

Client Intake Form

Release and Acknowledgement