Client Intake Form

Client Intake Form
Client Name

First NameLast Name
Birth Date

MonthDayYear
Date
Dominant Hand
What is your bed time and wake time?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Please state if you have current/previous health diseases/issues.
Please state whether you take any medication.

Health & Lifestyle

Rows	Yes	No
Do you smoke?
Within in the last year, have you had any surgery?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Do you feel pain while participating in sports/exercise?
Have you consulted your physician regarding increasing your physical activity and/orperforming a fitness assessment?
If you answer NO to question 8, will you consult your physician prior to increasingyour physical activity and/or performing a fitness assessment?

Medical History: Check any and all medical conditions that apply to you from the list below:
Food/nutrition
Do you currently track your nutrition?
What is your estimated calorie intake?
Typically, how many meals do eat per day?

0

1

2

3

4

5

0 is Never, 5 is Always
Typically, how many meals do you eat outside the home per week?

0

1

2

3

4

5

0 is Never, 5 is Always
Would the majority of these meals be described as:
Estimate how much money you have spent on “bad” habits (fast food, soda, alcohol, smoking, etc.) since you were last in shape.
please enter a dollar amount
Are you willing to spend a fraction of that to obtain your goal?
What is your rate for your nutrition?

0

1

2

3

4

5

0 is Poor, 5 is Excellent
Please select the reasons you eat (besides hunger).
Exercise/Movement
How often can you exercise per week?
How many months are you willing to commit to exercise?
Please select the best days you can exercise.
Please select the best times you can exercise.
What are your goals for training?

Other
Release and Acknowledgement
I, {clientName}, 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.
Date

MonthDayYear
Date
Client Signature
Should be Empty:

Client Intake Form

Food/nutrition

Exercise/Movement

Release and Acknowledgement