Client Intake Form

01 Personal Information

First Name *

Last Name *

Date of Birth

Email *

Phone

City / State

Height

Current Weight

02 Emergency Contact

Name

Relationship

Phone

03 Health & Medical History

Do you have any current injuries or pain? If yes, please describe

Have you had any surgeries or major medical procedures?

Any health conditions we should know about? (diabetes, heart condition, high blood pressure, etc.)

Are you currently taking any medications that may affect exercise?

Have you been cleared by a doctor to exercise?

Yes No — I should check first Not needed / no conditions

Are you pregnant or postpartum?

No Currently pregnant Postpartum (within 1 year) Prefer not to say

04 Fitness Background

How would you describe your current fitness level?

Complete Beginner Some Experience Intermediate Advanced

How many days per week are you currently active?

0 — not active 1–2 days 3–4 days 5+ days

05 Your Goals

What is your primary goal? *

Lose Weight / Body Fat Build Muscle / Tone Improve Fitness / Endurance Improve Strength Feel More Confident Improve Overall Health Postpartum Recovery Other

Describe your goal in your own words — what does success look like to you?

What is your timeline?

Goal weight (if applicable)

What has stopped you from reaching this goal in the past?

06 Lifestyle & Schedule

What is your occupation / activity level at work?

Mostly sedentary (desk job) Lightly active (on feet part of day) Very active (physical labor) Stay at home / caregiver

How many days per week can you commit to working out?

When do you prefer to work out?

Early morning Morning Afternoon Evening Late night Varies / flexible

Average hours of sleep per night

7

3 hrs11 hrs

Current stress level (1 = low, 10 = very high)

5

1 — Low10 — High

07 Nutrition & Habits

How would you describe your current eating habits?

Pretty healthy already Mostly healthy, some bad habits Could definitely be better Need a full reset

Do you have any dietary restrictions or preferences?

How many glasses of water do you drink daily?

How many meals / snacks do you typically eat per day?

Anything else about your nutrition we should know?

08 Equipment & Training Location

Where will you be working out? (check all that apply)

At Home Gym Membership Outside / Park Hotel / Travel

What equipment do you have access to? (check all that apply)

Dumbbells Barbells / Rack Resistance Bands Pull-up Bar Kettlebells Cardio Machine Full Gym No Equipment

If you have dumbbells, what's the heaviest weight you own?

09 Motivation & Mindset

Client Intake Form

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