Fitness Client Intake Form

Client Initial Form
Client Name

First NameLast Name
Birth Date

MonthDayYear
Date
Phone Number
Email
[email protected]
Social media (Instagram only)
@examplesocialmedianame
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please state if you have current/previous health diseases/surgeries/issues.
Please state whether you take any medications or supplements. ( list each and what time of day you take it and why)

Health & Lifestyle

	Yes	No
Do you smoke?
Have you had any surgery since one year?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Are you tracking your daily food intake?
Have you done sports professionally before?
Do you feel pain while doing sports/exercise?

At which frequency you eat at night?

0

1

2

3

4

5

0 is Never, 5 is Always
At which frequency you eat lunch?

0

1

2

3

4

5

0 is Never, 5 is Always
At which frequency you eat Dinner ?

0

1

2

3

4

5

0 is Never, 5 is Always
At which frequency you eat snacks ?

0

1

2

3

4

5

0 is Never, 5 is Always
What is your rate for your nutrition?

0

1

2

3

4

5

0 is Poor, 5 is Excellent
What’s your availability for exercise daily ?
1 hrs. Or 1 hrs 3min example
How often will you do exercise weekly ?
Example: 5 days a week
Where do you struggle most with your eating habits & exercise?
Example: I love cookies before bed.
Please select the reasons you eat (besides hunger).

StressDepressionBoredomHappinessHabitAnnoyance
Name

First NameLast Name
Please select the best days you can exercise.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please select the best times you can exercise.

Early MorningsMorningsEarly AfternoonsAfternoonsEvenings
What are your goals for training?

Development of musclesReducing the stressLosing body fatIncreasing the motivationTraining for an event/specific sportsOther
What is your 3 major reasons for this lifestyle change ? (What will motivate you most on your toughest days)
Release and Acknowledgement
I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential.

Sonina Jones Rowell , the fitness coach has informed me that I am the only responsible party for all the injuries during the fitness program and incorrect information. I release and discharge the fitness coach from any disclosure of my personal information in this Fitness Accountability Client Intake Form.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the fitness coach immediately.
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Client Signature

Clear
Should be Empty:

Client Initial Form

Release and Acknowledgement