Fitness Client Intake Form

Personal Training Application

Please fill out as much information as possible.
Client Name

First NameLast Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
Gender

MaleFemale
Height
Feet and inches
Current weight
lbs.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please list any current/previous health diseases/issues.
Please list any current medications.

Health & Lifestyle

	Yes	No
Do you smoke?
Have you had any surgeries in the past year?
Do you drink alcohol?
Are you using any additional vitamins or supplements?
Are you tracking your daily food intake?
Have you done sports professionally before?
Do you feel pain while doing sports/exercise?

How would you rate for your nutrition?

0

1

2

3

4

5

0 is Poor, 5 is Excellent
Are you on any kind of special diet? If so, list
What are your goals for training? Check all that apply

Increased strength/muscle growthWeight lossStress reductionIncreased motivation to exerciseTraining for an event/specific sportsOverall health and fitness
How committed are you to seeing your goals met

0

1

2

3

4

5

0 is Not at all, 5 is Completely
List what you would consider to be your biggest challenges to meeting your training goals (e.g. physical issues, time, family commitments, etc.)
How often are you willing to exercise per week?
How many months are you willing to commit to at the start?
Please select the best days for you to exercise.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please select the best times you can exercise.

Early MorningsMorningsEarly AfternoonsAfternoonsEvenings
List any physical activities in which your currently participate (e.g. sports, daily walking)
What is the activity level at your job?

None (seated)Moderate (some activity such as walking)High (heavy labor/very active)N/A
Which Option Are You Most Interested In? (See option page in website for details)

Option 1 - Fully onlineOption 2 - In-person 1x/monthOption 3 - In-person 2x/monthOption 4 - In-person 4x/monthOnly In-person Training Sessions
Additional comments or questions
Release and Acknowledgement
I hereby acknowledge that the information I've given above is complete and accurate. I am informed that my information in this form will be kept confidential.

I understand that physical exercise can be strenuous and subject to risk of injury and that it would be in my best interest to obtain a physical examination from my doctor prior to beginning any training. I understand that by participating in the exercises and training sessions, I do so at my own risk, accepting all responsibility for any undesired situations during training.

I have been informed that I am the only responsible party both for any injuries during the fitness program and incorrect information. I release and discharge the fitness trainers, administration and workers from any and all claims or causes of action. This waiver and release of liability includes, without limitation, all injuries that may occur during exercises or training.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the the trainer(s) immediately.

I acknowledge that i have carefully read this waiver and release and fully understand that it is a release of liability.
Date

MonthDayYear
Date
Client Signature

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Personal Training Application

Release and Acknowledgement