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Client Intake Form

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The following questions are designed for the purpose of reviewing and determining your health history, possible risk factors, fitness and activity level, attitude and lifestyle. We recommend that anyone starting an exercise program should consult with a physician prior to starting.

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Medical Information
Health Information

Do you now, or have you had in the past (treatment, diagnosis):

Occupation and Leisure Information

Some studies have shown that stress can affect physical health. Understanding the role stress plays in your occupational and leisure time will be integral in developing your customized exercise program. Please choose the answer best suited to your current situation.

What is your current occupation and how long have you worked in the industry?

Dietary Habits
Goal Evaluation

Rank your goals in starting an exercise program. (1 is Not Important and 5 is Extremely Important)

Goal Setting

Specifically describe what you would like to accomplish with an exercise program throughout your Personal Training experience:

Thank you for completing this form. It will help considerably as we develop a training program just for you. Please select whether you want a copy of this form emailed to your or not and click Save to complete the submission.

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