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Client Intake Form
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What is your name?
Your answer
What is your email?
Your answer
What is the best phone number to reach you at?
Your answer
Age:
Your answer
Sex:
Male
Female
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What is your current weight?
Your answer
Have you worked with a trainer before?
Yes
No
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If yes, describe your experience with your previous trainer(s).
Your answer
What are your short term (6-8 weeks) and long term (16-24 weeks) goals?
Your answer
What is keeping you from achieving your goals?
Your answer
How long have you been struggling with this?
Weeks
Months
I can't get this monkey off my back.
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What have you tried in the past?
Your answer
How many days per week do you currently exercise?
0
1-2
2-3
4-5
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What do you currently do for exercise?
Your answer
Do you have any limitations, past or present injuries, or chronic pains?
Your answer
How would you describe your relationship with food/diet?
Your answer
How did you hear about me?
Facebook
Instagram
Family/Friend
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Are you willing and able to commit a few hours per week to invest in your future self?
Yes
No
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