Personal Training Informational Intake Form

Name *

First

Last

Date of Birth

Age

Height

Sex

Time Zone

For scheduling

Genetic Background

*Not Required

Contact Phone Number

Email *

Mailing Address

Your Job and Nature of Business

Example: Sales at a large discount store, I work Monday through Friday from 8-5, I am on my feet all day. We use this to better understand what obstacles to your program may arise.

Do you smoke cigarettes?

No
Yes

If so, how many packs per day?

Do you drink alcohol?

No
Yes

If so how much and how often (on average)?

example: 3 days per week, 2 drinks per occasion

Allergies - Food, Medication, Environmental

Please list all known allergies and your reaction to each.

Medical Conditions

Such as heart problems, diabetes, etc. If so, what?

Please describe and injuries, surgeries or general pain and limitations that you currently suffer from or have had in the past.

Example: Knee replacement on left knee in 2016.

Do you take medications or supplements?

Yes
No

If so, what?

Do you know of any reason you should not begin a training/exercise/nutrition program?

In your own words, what is you current fitness level?

Do you weight train, do cardio, etc?

If you exercise, please describe your exercise program.

Example: I do cardio on an elliptical 3 times per week and do a circuit weight training at Curves once per week.

Do you understand that this will be a lifestyle change and may take time to reach your results?

Yes
No

Once you have reached your goals, you will be able to stick to this program parameters and live a healthy happy life, this is a lifestyle change program, not a fad diet or workout program.

How important is becoming healthier to you?

Not important
Somewhat important
Very important

Tell me about your health goals and what you are hoping to accomplish over the next 12 months.

Why are achieving these goals important to you?

Have any specific life events caused major changes in your health?

Yes
No

Health diagnosis, retirement, accident, injury, addiction, etc

If yes please describe.

What life event or events have caused changes in your health.

What made you decide now was the time to start working towards your goals? Why not next month or next year?

Tell me about the people in your life who will benefit from this investment in your health.

How will this change effect your spouse, partner, children, and/or family?

How supportive are other people in your life for you to make these positive changes?

Not supportive
Somewhat supportive
Very supportive

What specific foods, activities, or distractions make you feel better?

What specific foods, activities, or distractions make your feel worse?

Please list habits in your life currently that will need changing to reach your goals.

Tell me about some habits you will need help adjusting to reach your monthly goals. (e.g. fast food, smoking, alcohol, watching too much T.V. at night, etc)

How long do you envision it taking to reach your goals?

Where will you be in 6 months? Where will you be in 12 months?

How will your life be different when you reach these goals?

Who or what inspires you the most to reach your goals? Why?

If you start falling back to old habits, how can we help get you back on track?

In the next year, when the going gets tough and you are having a hard time coming in, what can we say or do that will motivate you to get back on track?

What are the best days of the week for you to commit to training?

What is your average daily schedule?

What time do you wake up? Go to work? Eat? Go to sleep? Are you on your feet all day? Watch much TV? etc.

Food Log - One Average Day

Please write down what you would eat on an average day, include all meals, snacks, and beverages.

Do you follow any special diet or have diet restrictions or limitations for any reason?

Health, cultural, religious, or other.

Who prepares the majority of your meals?

Who shops for food?

How many meals per week do you eat at a restaurant or get carry outs?