Personal Trainer Client Intake and Liability Form

Client Intake Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Email*
What is the best way to contact you?*

Phone callEmailTextMessengerOther
Past Information
Were your parent(s) physically active in your childhood? For example working out 3-4x per week.

YesNo
Was physical fitness a big part of your childhood?

YesNo
Give me a brief description of your physical fitness from your high school through to your mid 20's.
Was there pressure to succeed?

YesNo
If yes, did it dissuade you to slow down or quit that activity all together? Elaborate if you can.
How do you feel about physical fitness now?
Lifestyle Information
Tell me about your family dynamics (spouse/kids/animals/
How would you rate the stress of your family lifestyle?

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1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown
Elaborate on what you find stressful, within the family dynamics.
Are there any hobbies or activities that you helps you deal with your stress?
What is your activity level at your home?

noneLow (light activity such as walking)Moderate (Walks plus working out 2x/weekly)High (Walks plus working out 3x/weekly)Intense (Walks plus working out 5x/weekly)
What do you do for a living?
Do you follow a regular working schedule, do you work days, afternoon or nights?
What is the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
How would you rate the stress of your job?

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1 is No or little stress, 10 is Overwhelming stress/verge of nervous breakdown
Elaborate on what you find stressful at work?
Current Information
What were some of your fitness goals?
What possible personal barriers do you feel kept you from reaching your nutritional and fitness goals?

Lack of motivationTimeSelf ConsciousLack of equipmentLack of ResultsHitting A PlateauMoneyNot knowing where/how to beginOther
Do you notice any patterns or triggers that make it difficult to stay motivated or consistent with your fitness routine?
What are some of your strengths and resources that you can draw upon to overcome some of these triggers?
Do you meditate now or ever in the past?

YesNo
If yes, how was the experience for you?
If no, are you wiling to start with some baby steps?*

YesNo
Training and Exercise History
Have you trained with a personal trainer before?

YesNo
If yes, was your previous experience negative or positive? Why?
Describe what you expect of me as your fitness coach.*
How often are you willing to train per week to reach goals?
Please rate your mental readiness to make changes to reach your goal.*

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1 is I am not ready to make any changes. , 10 is I'm ready to make any lifestyle changes to reach my goals!
Please rate your motivational level to do what it takes to reach your goal.*

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1 is I have no motivation to change my life., 10 is I'm ready to make any lifestyle changes to reach my goals!
What motivates you?

Need a strong motivator to push you to exerciseYou like to be informed about your program and how it is going to lead you to your goalsLike to try new things if they are effectiveWilling to push past your comfort level to reach your goalsIf I feel things are really hard I tend to back offNeed to be held accountable for what I am doingBeing sore the day after a workout tells me my workouts are workingOther
Can you accept responsibility for the way your body is today and understand that, while your old habits don't make you a bad person, they still need to be changed?*

YesNo
Should be Empty:

Client Intake Form

Past Information

Lifestyle Information

Current Information

Training and Exercise History