Fitness 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

Email

example@example.com

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please list any relevant current/previous health diseases/issues.

Please list any medication or supplements you currently take.

Health & Lifestyle

	Yes	No
Do you smoke?
Have you had any surgery since one year?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Have you done sports professionally before?
Do you feel pain while doing sports/exercise?

How many hours of sleep a night on average?

5 is Low, 10 is High

How many meals a day, not including snacks?

0 is Low, 5 is High

How would you rate your diet?

0 is Poor, 5 is Excellent

In the past three months, how often have you engaged in physical activity?

0 is Less than once/week, 5 is 5+ times / week

How many days can you exercise per week?

Please select the best days you can exercise.

Lifestyle information (family/kids— anything that would have an effect on training, otherwise leave blank)

If you don't belong to a gym, what equipment do you have access to for strength training (e.g. bands, stability ball, dumbbells, pull up bar, etc.)

What are your goals for training?

I 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.

The fitness center 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 the fitness center trainers, administration and workers 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 the fitness center authorities immediately.

MEDIA RELEASE WAIVER
I, [Full Legal Name], residing at [Address], hereby grant [Organization/Company Name] ("the Organization"), its affiliates, agents, and assigns, the irrevocable and unrestricted right to:

Use, reproduce, distribute, and publish my likeness, image, voice, name, and/or biographical information in any form of media (including but not limited to photographs, video recordings, audio recordings, digital media, print, and online platforms) for promotional, educational, or commercial purposes.
Edit, alter, or modify the media as deemed necessary by the Organization, while ensuring that such modifications do not create a false or misleading representation.
Use the media in perpetuity without any expectation of compensation, unless otherwise agreed upon in writing.
I understand that:

I waive any right to inspect or approve the final media or its use.
This release is binding upon me, my heirs, and legal representatives.
The Organization is not obligated to use the media in any way.

Date

Client Signature

Fitness Client Intake Form

Release and Acknowledgement