Personal Training Intake Assessment PLEASE READ AND SIGN BELOW PT Intake Assessment Full Name * Phone / Email * I identify as and use the pronouns… Male / Him / He Female / Her / She Non-Binary / They / Them Date of Birth * Height (Feet/Inches) * Weight (Pounds) * Lifestyle What are your health concerns? * Rate your general stress level: * 1 2 3 4 5 6 7 8 9 10 (1 = Not at all stressed, 10 = Very stressed) What are your stress coping mechanisms? * What is your experience with exercise? * Rate your quality of sleep: * 1 2 3 4 5 6 7 8 9 10 (1 = Very poor, 10 = Excellent) How many hours do you sleep on average? * Rate your daily average activity level: * 1 2 3 4 5 6 7 8 9 10 (1 = Not at all active, 10 = Extremely active) What hours of the day are you most productive? * What are your biggest motivators? * What unhealthy habits do you have? * What are your exercise goals? * What are your physical weaknesses? * What are your hobbies? * How much screen time do you average per day or per week? * Medical History Are you currently taking any medications? If so, please list them: * Do you have any medical conditions? If so, please list them: * Are there any hereditary illness or disease in your family? If so, please list them: * Do you smoke? * Dietary Habits How many meals do you eat per day? * Describe your typical breakfast: * Describe your typical lunch: * Describe your typical dinner: * What are your go-to snacks? * How much water do you drink per day? * Do you have any allergies? If so, please list them: * 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. Full Name: * Today’s Date * Signature * Clear If you are human, leave this field blank. SUBMIT INTAKE ASSESSMENT Δ
