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404 Clement St • San Francisco, CA 94118

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Home
Fitness Tips Blog
Contact
Jobs

Why Us?
What’s Included?
- Custom Designed Workout Program
- Semi-Private Training Sessions
Memberships
For Members
Offers
- 14-Day $99 Trial Membership
- Gift Cards
Join Us

Client Intake Form

Client Information Questionnaire

1Start

2Physical

3Lifestyle

4Fitness / Nutrition

5Exercise / Goal Setting

6Complete

Personal Information
First Name*
Last Name*
Date of Birth*
Age*
Contact Information
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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)?*
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)?*
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)?*
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?
Email
This field is for validation purposes and should be left unchanged.

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(415)-928-WELL
404 Clement St • San Francisco, CA 94118

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