Client Intake Form
Full Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
*
Format: (000) 000-0000.
Email
*
What is the best way to contact you?
*
Phone call
Email
Text
Messenger
Other
Past Information
Were your parent(s) physically active in your childhood? For example working out 3-4x per week.
Yes
No
Was physical fitness a big part of your childhood?
Yes
No
Give me a brief description of your physical fitness from your high school through to your mid 20's.
Was there pressure to succeed?
Yes
No
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?
No or little stress
1
2
3
4
5
6
7
8
9
Overwhelming stress/verge of nervous breakdown
10
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?
none
Low (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?
No or little stress
1
2
3
4
5
6
7
8
9
Overwhelming stress/verge of nervous breakdown
10
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 motivation
Time
Self Conscious
Lack of equipment
Lack of Results
Hitting A Plateau
Money
Not knowing where/how to begin
Other
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?
Yes
No
If yes, how was the experience for you?
If no, are you wiling to start with some baby steps?
*
Yes
No
Training and Exercise History
Have you trained with a personal trainer before?
Yes
No
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 Select
1-2
2-3
3-4
4-5
5-6
6-7
7+
Please rate your mental readiness to make changes to reach your goal.
*
I am not ready to make any changes.
1
2
3
4
5
6
7
8
9
I'm ready to make any lifestyle changes to reach my goals!
10
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.
*
I have no motivation to change my life.
1
2
3
4
5
6
7
8
9
I'm ready to make any lifestyle changes to reach my goals!
10
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 exercise
You like to be informed about your program and how it is going to lead you to your goals
Like to try new things if they are effective
Willing to push past your comfort level to reach your goals
If I feel things are really hard I tend to back off
Need to be held accountable for what I am doing
Being sore the day after a workout tells me my workouts are working
Other
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?
*
Yes
No
Save
Submit
Should be Empty: