Personal Training Client Intake Form

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

years

Email

example@example.com

If you have any diagnosed health problems list the condition(s).

If you have any injuries, please list them (note if you are receiving rehab, Physio, doctors assistance etc).

Please list:

Time of day that would suit for a consultation:

Are you wanting your consultation:

Please rate your readiness for change.

What following goals does best fit in with your goals?

What is your goal with your training? Why?

What kind of training did you do?

1.) LIABILITY

I understand that physical training carries inherent risks and I participate voluntarily, accepting full responsibility for my health and safety. I release Locked In PT and Latifah Pascoe from any liability for injuries sustained during participation.

2.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

I AGREE TO THE ABOVE TERMS & CONDITIONS!

Book a free consultation

Part 1. Basic information

Part 3. Medical and Health Information

Part 4. Goals

Please Read The Following Terms and Conditions