Personal Training Client Intake Form

Information you will need

• What's your gender?
• Do you feel pain in your chest when you do physical activity?
• In the past month, have you had chest pain when you were not doing physical activity?
• Do you lose balance because of dizziness or do you ever lose consciousness?
• Are you pregnant now or have given birth within the last six months?
• Do you take any medications on a regular basis?
• What medications do you take?
• Do you know of any other reason why you shouldn't do physical activity?
• Can you expand on your health issues or concerns?
• Do you smoke?
• How many cigarettes do you smoke in a day?
• Do you drink alcohol?
• How many alcoholic beverages do you drink in a week?
• How many hours do you regularly sleep at night?
• How active or physically demanding is your job?
• Have you had a recent surgery?
• Do you have health problems that cause you pain or limitations in movement?
• Do you have a heart condition that limits your ability to do physical activity recommended by a doctor?
• Personal Trainer af image
• PERSONAL TRAINER ONLY: What's your name?
• CLIENT ONLY: What's your name?
• What's your street address?
• What's your city?
• What's your state?

…and 31 more fields in the PDF.

Completed by the client.

The form includes 1 signature line.