(415)-928-9355
523 Clement St • San Francisco, CA 94118
Fitness Tips Blog
Contact
Jobs
Menu
Why Us?
For Fitness Fans
For Athletes
Training Team
Our Story
Client Reviews
FAQs
Gym Facility
Coaching Internships
What’s Included?
Custom Designed Workout Program
Semi-Private Training Sessions
Memberships
Pricing
Join Us!
Training Schedule
For Members
Latest Member Updates
Training Schedule
Schedule A Training Session
Offers
14-Day $99 Trial Membership
Gift Cards
Join Us
Home
Fitness Tips Blog
Contact
Jobs
Why Us?
For Fitness Fans
For Athletes
Training Team
Our Story
Client Reviews
FAQs
Gym Facility
Coaching Internships
What’s Included?
Custom Designed Workout Program
Semi-Private Training Sessions
Memberships
Pricing
Join Us!
Training Schedule
For Members
Latest Member Updates
Training Schedule
Schedule A Training Session
Offers
14-Day $99 Trial Membership
Gift Cards
Join Us
Client Intake Form
Client Information Questionnaire
1
Start
2
Physical
3
Lifestyle
4
Fitness / Nutrition
5
Exercise / Goal Setting
6
Complete
Personal Information
First Name
*
Last Name
*
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Age
*
Contact Information
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Primary Phone Number
*
Occupation
*
Emergency Contact Name
*
Relationship
*
Emergency Contact Phone
*
Physical Activity Readiness
Has your doctor ever said that you have a heart condition and recommended only medical supervised physical activity?
*
Yes
No
Do you frequently have pains in your chest when you perform physical activity?
*
Yes
No
Have you had chest pain when you were not doing physical activity?
*
Yes
No
Do you lose your balance due to dizziness or do you ever lose consciousness?
*
Yes
No
Do you have or have you had a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, heart disease, by-pass, stroke, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, any serious or chronic illness, allergies, etc.)?
*
Yes
No
Are you pregnant now or have given birth within the last 6 months?
*
Yes
No
Have you had a recent surgery?
*
Yes
No
On the questions you marked YES above, please elaborate here:
*
Do you take any medications, either prescription or non-prescription, on a regular basis?
*
Yes
No
What is the medication for?
*
How does this medication affect your ability to exercise or achieve your fitness goals?
*
Lifestyle
Do you smoke?
*
Yes
No
How many?
*
Do you drink alcohol?
*
Yes
No
How many glasses per week?
*
How many hours do you regularly sleep at night?
*
Describe your job:
*
Sedentary
Active
Physically demanding
Does your job require travel?
*
Yes
No
On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)?
*
1
2
3
4
5
6
7
8
9
10
List your 3 biggest areas of stress:
1.)
*
2.)
*
3.)
*
Is anyone in your family overweight?
*
Mother
Father
Sibling
Grandparent
No
Were you overweight as a child?
*
Yes
No
At what age?
*
Nutrition
On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?
*
1
2
3
4
5
6
7
8
9
10
What activities do you engage in while eating? (TV, reading, etc.)
*
How many glasses of water do you consume daily?
*
How many diuretics (caffeine [coffee, tea, etc.], alcohol, etc.) do you consume daily?
*
Do you feel drops in your energy levels throughout the day?
*
Yes
No
Sometimes
When?
*
How many times per week do you eat out?
*
Do you do your own grocery shopping?
*
Yes
No
Do you do your own cooking?
*
Yes
No
List 3 areas of your Nutrition you would like to improve:
1.)
*
2.)
*
3.)
*
Fitness & Exercise
When were you in the best shape of your life and what were you doing at that time?
Have you been exercising consistently for the past 3 months?
*
Yes
No
What if anything stopped you in the past?
*
On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?
*
1
2
3
4
5
6
7
8
9
10
How many days per week do you take part in physical exercise?
*
5-7
3-4
1-2
What types of physical activities do you participate in?
*
If your participation is lower than you would like it to be, what are the reasons?
*
Lack of interest
Illness/injury
Lack of time
Goal Setting
How can a Personal Trainer help you? Please check that which applies.
*
Lose body fat
Develop muscle tone
Rehabilitate an injury
Nutrition education
Start an exercise program
Design a more advanced program
Safety
Sports specific training
Increase muscle size
Fun
Motivation
Weight loss
Other
What are other ways we can help?
Where do you rate health in your life?
*
Low priority
Medium priority
High priority
What do you feel are the obstacles to achieving your fitness goals?
*
Miscellaneous
How did you hear about us? Please check that which applies.
*
Brochure
Word of mouth
Yelp
Website
Other
If "Other" above, please tell us how you heard about us?
If you were referred to us, who told you about our services?
If you found us using a search engine, what search term did you use?
Why did you choose to train with Advanced Wellness instead of another organization? Please check that which applies.
*
Location
Personal trainers
Cost
Customer service
Word of mouth
Programs
Other
You will be contacted within 24 hours. Assuming we are confident we feel we can help you, what days and times are you availble for your 30-minute, initial appointment/assessment?
Any Question/Comments?
Comments
This field is for validation purposes and should be left unchanged.
follow us
@AWtrainingsf