Let’s Work Together Client Intake Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship To Contact * What services are you interested in? * Check All That Apply Nutrition Consultation Fitness Consultation Small Group Training One-on-One Personal Training What Date Can You Start? * MM DD YYYY Message * Occupation * Does Your Job Require Frequent Long Distance Travel? * Yes No How did you hear about us? Social Media Google Website Referred by Someone Other Rate Your Average Daily Stress Level * 1 = Very Low, 10 = Very High How Many Hours Do You Sleep At Night * On Average Do You Smoke? * Yes No If yes to smoking, how often? What Are Your Fitness Goals * Rate Your Fitness Level * 1-10, 1 = poor, 5 = average, 10 = very fit What activities do you do for strength exercises? * (e.g. weights, calisthenics, pilates) Number of Days Per Week (Strength Training) * What activities do you do for aerobics? * (e.g. group classes, running, walking, tennis) Do You Have Any Preexisting Injuries/Limitations? * If none, type "N/A" Number of days per week? (Aerobics) * Desired Personal Training Times & Dates * Number of Sessions You Can Attend Per Week * How Did You Hear About Us? Thank you!
