Personal Training Client Intake

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Have you been active in the last 6 months? (Walking counts!)

If so, please describe your typical routine.

If not, have you been active in the past? (Childhood counts!)

Do you currently compete in a sport?

If so, list all that apply.

Have you worked with a trainer before?

In a general sense, what are your goals in hiring a trainer? Select all that apply.

Lets get more specific. Do you have goals for outside the gym? Is there something you've always wanted to do, but never tried?

How sedentary is your job/daily routine?

*The following (3) questions are for female applicants. The answers are to ensure proper caution and techniques during training and will remain confidential. I fully understand that this can be an area of emotional stress and will only be discussed with client consent.

Are you pregnant or trying to become pregnant?

Have you been pregnant in the past?

Have you had a D&C, hysterectomy, or other female specific surgical procedures?

* Questions resumed for both Male and Female.

Have you ever worked with or been referred to a pelvic floor PT?

Do you have a history of hernias, diastasis, or prolapse of any kind?

Have you had any surgical procedures that included an incision to your abdomen?

List any prior injuries including adolescence. Ex: tears, ruptures, broken bones, sprains, etc.

List any current or previous disorders, diseases, or disabilities that you find should be considered in your training.

List any current medications.

How often do you consume an alcoholic beverage?

Do you smoke or vape?

On average, how many hours of sleep do you get each night?

Feel free to share any additional information you may find important for me to know.

What days are you available for a phone consultation? (Select all that apply)

What times are you available for a phone consultation? (Select all that apply)

Are you available for communication over text?

Thank you for taking the time to fill out this client intake form. All information provided will remain confidential. I will reach out within 48 hours to schedule our phone call with the contact information provided.

I look forward to meeting you!