Personal Training Client Intake

Personal Training Client Intake
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

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

YesNo
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?

YesNo
If so, list all that apply.
Have you worked with a trainer before?

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

Fat LossBuild MuscleStrengthAthleticismPosture CorrectionInjury Recovery/PreventionPressure management (core control)AccountabilitySport specific trainingKeeping up with children/grandchildrenPregnancy/PostpartumMobilityImproving overall quality of lifeOther
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?

Very SedentarySedenarySomewhat activeVery ActiveIt changes every day
*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?

YesNo
Have you been pregnant in the past?

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

YesNo
* Questions resumed for both Male and Female.
Have you ever worked with or been referred to a pelvic floor PT?

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

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

YesNo
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?

Only on special occasionsOnce a monthOnce a week2-3 a week3+ a weekI don't consume alcohol
Do you smoke or vape?

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

1-3 hours4-6 hours7+ hours
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)

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

9am-12pm12pm-3pm3pm-6pm6pm-9pm
Are you available for communication over text?

YesNo
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!
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