Personal Training Client Intake Form

PERSONAL TRAINING CLIENT INTAKE FORM
Disclaimer: Thank you for your interest in being a client of [PERSONAL TRAINER'S
NAME]. Information collected about new clients is confidential and will be treated
accordingly.
CLIENT INFORMATION
Name: _____________________ Gender: Male Female Other
Street Address: __________________________________________
City: _____________________ State: _____________________ Zip Code: ________
E-Mail: _____________________ Phone: _____________________
Preferred Contact Method: E-mail Phone Text Message
Emergency Contact: _____________________ Phone: ______________________
CURRENT FITNESS LEVEL & GOALS
Why do you want to work with a personal trainer? ___________________________

______________________________________________________________________
What are your fitness interests and favorite activities? _______________________

______________________________________________________________________
What are your fitness goals? _____________________________________________

______________________________________________________________________
On a scale of 1-10 (1 being bad and 10 being great), how would you rate your
current fitness level? ______
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HEALTH / PAR-Q FORM
Has your doctor ever said that you have a heart condition and should only do
physical activity recommended by a doctor? Yes No
Do you feel pain in your chest when you do physical activity? Yes No
In the past month, have you had chest pain when you were not doing physical
activity? Yes No
Do you lose balance because of dizziness or do you ever lose consciousness?

Yes No
Do you have a bone, joint, or other health problem that causes you pain or
limitations in movement? Yes No
Are you pregnant now or have given birth within the last six months? Yes No
Have you had a recent surgery? Yes No
Do you take any medications on a regular basis? Yes No

If so, what are the medications? ____________________________________________
Do you know of any other reason why you should not do physical activity?
Yes No
If you marked “Yes” to any of the above, please explain in detail below:
______________________________________________________________________
______________________________________________________________________
LIFESTYLE
Do you smoke? Yes No If yes, how many per day? _________
Do you drink alcohol? Yes No If yes, how many per week? _________
How many hours do you regularly sleep at night? _________
Describe your job: Sedentary Active Physically Demanding

Does your job require you to travel? Yes No
On a scale of 1-10, with 1 being low and 10 being high, how would you rate your
stress level? _________
DEVELOPING YOUR FITNESS PROGRAM
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How often do you take part in physical exercise? ___________________________
If your participation is lower than you would like it to be, what are the reasons?
Lack of interest Illness/Injury Lack of time Other: ______________________
Based on your commitment, how often would you like to see a trainer to help you
achieve your goals? 3x/week 2x/week 1x/week 2x/month 1x/month
What are the best days during the week for you to commit to your exercise
program? (check all that apply)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What are the best times for you to exercise? Morning Afternoon Evening
Realistically, how many times per week do you expect to exercise and for how
long each session? ____________________________________________________
Please list anything else that you may feel is a concern or information that has
not been disclosed that may be pertinent to being physically active or working
with a personal trainer:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
CANCELATION POLICY
I understand that it is my responsibility to keep track of all my training session

appointments. In the event that I must cancel an appointment, I will give 24 hours' notice.
If I do not give 24 hours' notice, my account will be subjected to the session charge and
that session may be forfeited.
CLIENT SIGNATURE
Signature: ______________________ Date: ______________________
Print Name: ______________________
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PERSONAL TRAINING CLIENT INTAKE FORM

Name: _____________________ Gender: Male Female Other

Street Address: __________________________________________

City: _____________________ State: _____________________ Zip Code: ________

E-Mail: _____________________ Phone: _____________________

Preferred Contact Method: E-mail Phone Text Message

Emergency Contact: _____________________ Phone: ______________________

CURRENT FITNESS LEVEL & GOALS

Why do you want to work with a personal trainer? ___________________________

What are your fitness interests and favorite activities? _______________________

What are your fitness goals? _____________________________________________

Do you lose balance because of dizziness or do you ever lose consciousness?

Have you had a recent surgery? Yes No

Do you take any medications on a regular basis? Yes No

Do you smoke? Yes No If yes, how many per day? _________

How many hours do you regularly sleep at night? _________

Describe your job: Sedentary Active Physically Demanding

I understand that it is my responsibility to keep track of all my training session

Signature: ______________________ Date: ______________________

Print Name: ______________________

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City: _________ State: _ Zip Code:

E-Mail: _ Phone: _

Emergency Contact: _ Phone: __

Signature: Date: