Client Intake Form

Client Intake Form (William Capo-Chichi)
Client/Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Inquiry & Social Media

If applicable*
How did you hear about me and my services? (William)
Social Media Handle(s) (Optional: Instagram, Facebook, TikTok, etc.)
Questionnaire
What are your fitness goals? (be as specific as you can)*
What are the barrier(s) that could prevent you from achieving your goals?
On a scale 1-10, rate your overall gym experience? (1-new to the gym; 10-experienced in the gym/minimum 1 year)

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
What are your goals you would like to achieve within 3 months? (short-term)
What are your goals you would like to achieve in one year? (long-term)
What time of the day are you most active?
Do your best to give an example of a typical breakfast, lunch, and dinner for yourself. How about snacks and drinks? (over the course of 2-3 days)
What you normally eat often*
What physical activity have you done in the past? (over your lifespan)
Sports background, daily leisure activities, etc.*
Physical & Medical

Please consult with a profession dietician and/or physician for treatments, prescriptions, etc.
List any physical concerns your trainer should be aware of, past or present? (Injuries, Arthritis, Tears/Fractures, Muscle/Movement Restrictions, etc.)
See a professional physician for further assistance*
List any medical concerns your trainer should be aware of, past or present? (Allergies, Asthma, Heart Issues, etc.)
See a professional dietician for further assistance*
Rate these categories in order of importance: Use a 1-5 scale
Weight Loss/Physique

1

2

3

4

5

1 is Worst, 5 is Best
Strength/Muscle Gain

1

2

3

4

5

1 is Worst, 5 is Best
Athletic/Exercise Performance

1

2

3

4

5

1 is Worst, 5 is Best
Mobility Improvement

1

2

3

4

5

1 is Worst, 5 is Best
Health/Lifestyle Improvement

1

2

3

4

5

1 is Worst, 5 is Best
Which style of training are you most interested in?
Appointment (caution: date/time due to availability)* Primary Location: The Vault YEG; 16313 111 Ave NW Edmonton, AB T5M 2S2
Signature (proof of completion)*
Should be Empty:

Client Intake Form (William Capo-Chichi)

Client/Personal Information

Inquiry & Social Media

Questionnaire

Physical & Medical

Rate these categories in order of importance: Use a 1-5 scale