Fitness Client Intake Form

Fitness Client Intake Form
1 Full Name
2 Date of Birth

MonthDayYear
Date
Age
3. Phone Number
Format: (000) 000-0000.
4 Email Address
example@example.com
5 Address
6. Emergency Contact Name
7. Emergency Contact Phone
Format: (000) 000-0000.
SECTION 2: MEDICAL & HEALTH HISTORY
Are you currently under the care of a physician?

YesNo
If yes please explain
Do you have any medical conditions or physical limitations?

YesNo
If yes please list
Are you currently taking any medications?

YesNo
If yes please list
Have you had any surgeries or injuries in the past 2 years?

YesNo
If yes please describe
Do you smoke or use tobacco products?

YesNo
Do you have any allergies or dietary restrictions?

YesNo
If yes please list
SECTION 3: FITNESS & LIFESTYLE
What is your current activity level?

SedentaryLightModerateVery Active
What are your fitness goals? (Check all that apply)

Weight LossBuild MuscleImprove EnduranceGain StrenghtIncrease FlexibilityImprove HealthOther
Other
Have you worked with a personal trainer before?

YesNo
If yes what did you like or dislike
How many days per week would you like to train?
Do you follow any specific diet or nutrition plan?

YesNo
If yes please describe
SECTION 4: READINESS & CONSENT
1. On a scale of 1 to 10, how committed are you to reaching your fitness goals? (1 = not committed, 10 = fully committed):
2. Is there anything else Shereen should know to help personalize your fitness journey?
I acknowledge that the information provided is accurate to the best of my knowledge.
Signature
Date

MonthDayYear
Date
Should be Empty: