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

Format: (000) 000-0000.

Email

example@example.com

Gender

Height

Feet and inches

Current weight

lbs.

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

Please list any current/previous health diseases/issues.

Please list any current medications.

Health & Lifestyle

Rows	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 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

How committed are you to seeing your goals met

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.

Please select the best times you can exercise.

List any physical activities in which your currently participate (e.g. sports, daily walking)

What is the activity level at your job?

Which Option Are You Most Interested In? (See option page in website for details)

Additional comments or questions

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

Client Signature

Personal Training Application

Release and Acknowledgement