Client Intake Form

Client Intake Form
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Height
cm
Weight
kg
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
Do you have any dietary requirements, restrictions, or food allergies I should be aware of?
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 many hours of sleep do you get on average?
Are you happy to log your sessions or nutrition? (Yes/No)
Biggest obstacles to sticking with a program? (Time, motivation, knowledge, equipment)
Preferred training style (home, gym, bodyweight, equipment)
How many days per week are you looking at training?
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
Have you worked with a PT or followed a structured program before?
Preferred method of communication (WhatsApp, Email, Text, etc.)
Timezone
Should be Empty: