Personal Trainer Client Intake Form

Your Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Height
cm
Weight
kg
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any diagnosed health problems?
Are you taking any medications? If yes, please list below.
Do you have any injuries? If yes, please list below.
How does your current diet look like?
Do you smoke?

What is your daily activity level?

	1	2	3	4	5

1 is None, 5 is High

What is your daily stress level?

	1	2	3	4	5

1 is Low, 5 is High

How often do you want to do personal training a week?
Which of the following statements fit in with your goals?

Other

Please rate your readiness to change.

	1	2	3	4	5

1 is Worst, 5 is Best