Client Intake Form

Date

Name

First NameMiddle InitialLast Name

Email

example@example.com

YesNo

Address

City

State

Zip

Phone Number

Format: (000) 000-0000.

D.O.B.

Age

Gender

Best way to communicate?

Emergency Contact Name(s)

Relationship

Phone

Format: (000) 000-0000.

1.What is your current occupation?

2. Do you sit for long periods of time? Approximately how many hours per day?

3. Do you have extended periods of movement?

4. Do you wear shoes with heels? If so, how often?

5. What recreational physical activities do you regularly partake in? How often? (Skiing, golfing, rollerblading, paddle boarding, etc)

6. Do you have or have you ever had pain or injuries? (ankle, knee, hip, shoulder, lower back, etc) If "yes," list and describe your injuries (date, treatment plan, physical therapy, and recovery.

7. Have you had any surgeries? If "yes," what kind of surgery and when? Please list each one.

8. Has a medical doctor ever diagnosed you with a chronic disease such as Coronary Heart Disease (CHD), Coronary Artery Disease (CAD), Hypertension, High Cholesterol, or Diabetes? If so, please explain.

9. Are you currently taking any medications? Please explain

10. What is your resting heart rate? THR? Leave blank if you do not know.

11. Have you consulted with your physician about starting an exercise program?

12. What is the reason for today's visit and what is most important for you to accomplish today?

13. Describe your short term physique goals and long term physique goals.

14. What time do you normally wake up? Go to bed?

15. What time of day do you normally work out?

16. What type of cardio and/or other exercise are you doing? How many times per week? For what duration?

17. What supplements are you taking, and why?

18. Have you worked with a fitness professional in the past? If "yes," were you successful? Why or why not?

19. Are you coachable/ willing to be coached?

20. How many times per week are you willing to work out on your own?

21. What time of day do you prefer to do resistance training?

22. What time of day do you prefer to do cardio?

23. Please provide 1-3 days of food intake. What time did you eat and what did you eat?

24. How long are you willing to commit to your health program?

25. Do you need help with education, motivation, and/or accountability? Please explain.

26. How are you motivated to work out (group setting, self motivated, both)?

27. Are you interested in private or semi private training?

Provide as much information as you can for the questions below, leaving the rest blank. We will help you with this; don't worry if you don't know the answers.

Height

Weight

Weight goal

Weight mid goal

Body Fat b=

t=

S=

i=

% Body Fat Goal

Fat Pounds

Fat Pounds Goal

Lean body mass

Lean body mass goal

I certify that the above information is accurate. I understand that I may need a medical release before I begin an exercise routine. I release the liability of the trainer and Fuerte Fitness facility.

Signature (*Minors If Applicable)

Date