Personal Training Intake Assessment

PLEASE READ AND SIGN BELOW
PT Intake Assessment
I identify as and use the pronouns…

Lifestyle

(1 = Not at all stressed, 10 = Very stressed)
(1 = Very poor, 10 = Excellent)
(1 = Not at all active, 10 = Extremely active)

Medical History

Dietary Habits

Client Statement

I understand and acknowledge that the services provided are at all times restricted to consultation on health matters intended for general well being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.