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New Client Intake Form

Client Intake Questionnaire

Please complete all sections as thoroughly as possible. Your information is confidential and helps us design the safest, most effective program for you.

Step 1: Contact Information 1 of 13

Contact Information

Basic personal and emergency contact details.

First Name *

Last Name *

Date of Birth *

Gender

Email *

Phone *

Address

Marital Status

Occupation

Emergency Contact

Emergency Contact Name *

Relationship

Emergency Phone *

Emergency Email

Medical & Family History

Please answer the following about your medical history. If yes, provide details where prompted.

Have you ever had heart trouble or been told you have a heart condition?

Yes No

Has a doctor ever told you that you have elevated blood pressure?

Yes No

Do you ever experience dizziness or fainting spells?

Yes No

Have you ever experienced unexplained shortness of breath?

Yes No

Do you have or have you ever had joint, bone, or muscular problems?

Yes No

Have you ever been hospitalized or had surgery?

Yes No

If yes to any above, please provide details:

Have you ever been involved in a car accident?

Yes No

Have you ever had a head injury or concussion?

Yes No

Have you had any significant dental work (braces, extractions, implants)?

Yes No

If yes to any above, please provide details:

Family Medical History

Check any conditions that run in your immediate family (parents, siblings, grandparents).

Heart Disease High Blood Pressure Stroke Diabetes Cancer Osteoporosis Arthritis Mental Health Issues Obesity Lung Disease

Additional family history details:

Physical Traumas by Decade

Please list any significant physical traumas you've experienced during each period of your life (falls, fractures, sports injuries, accidents, surgeries, etc.).

Birth – Age 10

Ages 11 – 20

Ages 21 – 30

Ages 31 – 40

Ages 41 – 50

Ages 51 – 60

Ages 61 – 70

Ages 71+

Musculoskeletal Issues by Body Region

For each body region, note any current or past pain, injury, or limitation. Please specify which side of the body and the approximate date or year the injury was sustained.

Head / Jaw / Face

Side

Approx. Date/Year

Details

Neck / Cervical Spine

Side

Approx. Date/Year

Details

Shoulders

Side

Approx. Date/Year

Details

Elbows / Forearms

Side

Approx. Date/Year

Details

Wrists / Hands

Side

Approx. Date/Year

Details

Upper Back / Thoracic Spine

Side

Approx. Date/Year

Details

Lower Back / Lumbar Spine

Side

Approx. Date/Year

Details

Hips / Pelvis

Side

Approx. Date/Year

Details

Knees

Side

Approx. Date/Year

Details

Ankles / Feet

Side

Approx. Date/Year

Details

Sacrum / Tailbone

Side

Approx. Date/Year

Details

Conditions Checklist

Check any conditions or situations that currently apply or have applied to you in the past.

Scars Tattoos Piercings Moles Broken Bones Sprains / Strains Dislocations Tendinitis Bursitis Fibromyalgia Chronic Fatigue Arthritis Osteoporosis Scoliosis Herniated Disc Sciatica Plantar Fasciitis Carpal Tunnel Cancer Diabetes (Type 1) Diabetes (Type 2) Thyroid Disorder Epilepsy / Seizures Asthma COPD Sleep Apnea Insomnia Anxiety Depression PTSD ADD / ADHD IBS Crohn's Disease Acid Reflux / GERD Food Allergies Skin Conditions Autoimmune Disorder Blood Clotting Disorder Hernia Vertigo Migraines Chronic Pain Pacemaker / Implant Pregnant / Postpartum

Details for any checked conditions (dates, current status, etc.):

Functional Movement

Do you experience pain or difficulty with any of the following daily activities?

Getting in and out of bed

Yes No

Sitting for extended periods

Yes No

Standing for extended periods

Yes No

Walking or climbing stairs

Yes No

Bending or squatting

Yes No

Reaching overhead

Yes No

Lifting or carrying objects

Yes No

Twisting or rotating your torso

Yes No

Pushing or pulling

Yes No

Details on any movement limitations:

General Health Information

Current health metrics, physician information, and general wellness.

Height

Current Weight

Goal Weight (if applicable)

Primary Physician Name

Physician Phone

Date of Last Physical Exam

Date of Last Blood Work / Lab Work

Blood Pressure (if known)

Resting Heart Rate (if known)

Total Cholesterol (if known)

Blood Sugar / A1C (if known)

How would you rate your overall health?

Sleep

Average hours of sleep per night

Sleep quality

Any sleep-related issues? (snoring, apnea, insomnia, etc.)

Digestion

Do you experience regular digestive issues (bloating, gas, constipation, diarrhea)?

Yes No

If yes, please describe:

Hydration & Nutrition

Your daily intake habits help us understand your nutritional baseline.

What Do You Drink?

Glasses of water per day

Type of water

Cups of coffee per day

Cups of tea per day

Sodas or soft drinks per day

Do you add cream/sugar to beverages?

What Do You Eat?

Servings of fruits per day

Servings of vegetables per day

Servings of grains/bread per day

Servings of dairy per day

Servings of meat/protein per day

How often do you eat fried foods?

Types of fats/oils you typically use

How often do you eat sugary foods/sweets?

Do you use artificial sweeteners?

Type of salt you use

Do you regularly read food labels?

Yes No

Any foods that cause irritation or allergic reactions?

Do you feel your diet is excessive or deficient in anything?

Are you currently following a specific diet or nutrition plan?

Weight History

Has your weight changed significantly in the past year?

Yes No

If yes, how much and in what direction?

Exercise, Rest & Stress

Your current activity levels, rest habits, and stress management.

How would you describe your current activity level?

Aerobic / Cardiovascular Activities

List up to 3 aerobic activities you currently do.

Activity

Frequency

Duration

Activity

Frequency

Duration

Activity

Frequency

Duration

Strength / Resistance Training

List up to 2 strength activities you currently do.

Activity

Frequency

Duration

Activity

Frequency

Duration

Stretching / Flexibility / Mobility

List up to 2 stretching or mobility activities you currently do.

Activity

Frequency

Duration

Activity

Frequency

Duration

Exercise History

What sports or physical activities have you participated in throughout your life?

Do you have any limitations that affect your ability to exercise?

Rest & Relaxation

How would you rate your current stress level?

What are your main sources of stress?

What do you do to relieve stress or relax?

How many rest/recovery days do you take per week?

Medications & Supplements

List all current medications, over-the-counter drugs, and supplements you take.

Prescription Medications

List all prescription medications (name, dosage, reason):

Over-the-Counter Medications

List any OTC medications you take regularly:

Herbal Remedies & Supplements

List all supplements, vitamins, and herbal remedies:

Smoking & Alcohol

These habits can affect your training program and recovery.

Smoking / Tobacco / Vaping

Do you currently smoke, vape, or use tobacco?

If current or former, how much per day?

How many years?

If former, when did you quit?

Alcohol

How often do you consume alcohol?

Typical number of drinks per occasion

Type of alcohol preferred

Respiratory Symptoms & Nijmegen Questionnaire

This section screens for respiratory symptoms and breathing pattern disorders.

Respiratory Symptoms

Check any symptoms you currently experience.

Chronic cough Wheezing Shortness of breath at rest Shortness of breath with exertion Chest tightness Frequent sighing or yawning Mouth breathing Snoring Breath holding Hyperventilation

Nijmegen Questionnaire

For each symptom below, rate how often you experience it: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Very Often. A total score of 23 or higher may suggest a breathing pattern disorder.

Chest pain

0 1 2 3 4

Feeling tense

0 1 2 3 4

Blurred vision

0 1 2 3 4

Dizzy spells

0 1 2 3 4

Feeling confused

0 1 2 3 4

Faster or deeper breathing

0 1 2 3 4

Short of breath

0 1 2 3 4

Tight feelings in chest

0 1 2 3 4

Bloated feeling in stomach

0 1 2 3 4

Tingling fingers

0 1 2 3 4

Unable to breathe deeply

0 1 2 3 4

Stiff fingers or arms

0 1 2 3 4

Tight feelings around mouth

0 1 2 3 4

Cold hands or feet

0 1 2 3 4

Heart palpitations

0 1 2 3 4

Feelings of anxiety

0 1 2 3 4

Nijmegen Total Score: 0 / 64

Score of 23 or higher may indicate a breathing pattern disorder. This will be calculated automatically.

Goals & Additional Notes

Help us understand what you want to achieve and anything else we should know.

What are your primary fitness/health goals? *

What is your timeline or target date for these goals?

What has prevented you from reaching these goals in the past?

How many days per week are you available to train?

Preferred training time

Is there anything else you would like us to know?

Acknowledgment

I confirm that the information provided is accurate to the best of my knowledge. I understand that this information will be used to develop a safe and effective training program. I agree to notify my trainer of any changes to my health status. *

Full Name (Signature) *

Date *

✓

Thank You!

Your intake questionnaire has been submitted successfully. We'll review your information and be in touch soon to schedule your first session.

Client Intake Questionnaire

Contact Information

Emergency Contact

Medical & Family History

Family Medical History

Physical Traumas by Decade

Musculoskeletal Issues by Body Region

Conditions Checklist

Functional Movement

General Health Information

Sleep

Digestion

Hydration & Nutrition

What Do You Drink?

What Do You Eat?

Weight History

Exercise, Rest & Stress

Aerobic / Cardiovascular Activities

Strength / Resistance Training

Stretching / Flexibility / Mobility

Exercise History

Rest & Relaxation

Medications & Supplements

Prescription Medications

Over-the-Counter Medications

Herbal Remedies & Supplements

Smoking & Alcohol

Smoking / Tobacco / Vaping

Alcohol

Respiratory Symptoms & Nijmegen Questionnaire

Respiratory Symptoms

Nijmegen Questionnaire

Goals & Additional Notes

Acknowledgment

Thank You!

TESTIMONIALS

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