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First & Last Name
Birth Date
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone Number
Please state if you have current/previous health diseases/issues.
Please state whether you take any medication.
Do you smoke?
Yes
No
Have you had any surgery since one year?
Yes
No
Do you drink alcohol?
Yes
No
Are you using any additional vitamin or supplements?
Yes
No
Are you tracking your daily food intake?
Yes
No
Have you done sports professionally before?
Yes
No
Do you feel pain while doing sports/exercise?
Yes
No
At which frequency do you eat at night?
0 (Never)
1
2
3
4
5 (Always)
At which frequency do you eat breakfast?
0 (Never)
1
2
3
4
5 (Always)
What is your rate for your nutrition?
0 (Never)
1
2
3
4
5 (Always)
How often can you exercise per week?
How many months will you do exercise?
Please select reasons you east (Besides hunger).
Stree
Happiness
Depression
Habit
Boredom
Annoyance
Please select the best days you can exercise.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please select the best times you can exercise.
Early Mornings
Mornings
Early Afternoons
Afternoons
Evenings
What are your goals for training?
Development of muscles
Reducing the stress
Losing body fat
Increasing the motivation
Training for an event/specific sports
I, {clientName}, hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential. The fitness center has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I release and discharge the fitness center trainers, administration and workers from any disclosure of my personal information in this Fitness Client Intake Form. If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the fitness center authorities immediately.
Acknowledgement Date
SUBMIT