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Karolina Gymrat Fitness Coaching - Client Intake Form

Basic Information

Full Name

Date of Birth

Phone Number

Email Address

Emergency Contact Name

Emergency Contact Phone

Preferred Method of Contact

Phone

Text

Fitness Goals

Primary Fitness Goals

Fat Loss

Build Muscle

Increase Strength

Improve Endurance

Improve Mobility/Flexibility

General Health/Fitness

Other

What would you most like to accomplish in the next 12 weeks?

Specific areas you would like to focus on

Exercise Starting Point

Current Activity Level

Have you exercised consistently before?

Yes

What types of exercise have you done?

When did you last exercise consistently?

Strength-Training Experience

None

Beginner

Intermediate

Advanced

Cardio Experience

None

Beginner

Intermediate

Advanced

Exercises you enjoy

Exercises you dislike or prefer to avoid

Injuries & Health Concerns

Do you have any current or previous injuries?

Yes

Do you have any current back, neck, joint, or other pain?

Yes

Has a healthcare professional told you to restrict or modify physical activity?

Yes

Do you have any health condition or concern that could affect your ability to exercise safely?

Yes

Are you taking any medication that could affect your response to exercise?

Yes

Is there anything else your trainer should know?

Client Agreement

I understand that fitness coaching is not a substitute for medical care. I will inform my trainer of relevant changes that may affect my ability to exercise safely. When appropriate, I may be asked to obtain medical clearance before beginning or continuing exercise.

Agreement Confirmation

I have read and agree to the statement above.

Electronic Signature

Sign here

Signature Confirmation

I agree that my electronic signature serves as my signature on this intake form.