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Client Info
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Name
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Birthday
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/
DD
/
YYYY
Email address
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Phone number
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Emergency contact name & number
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Tell me about yourself! (Spouse, kids, hometown, job, etc)
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How would you describe your current state of health?
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List current medications/supplements, dosage, and how often you take them:
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List any health conditions or injuries (current or past) that you feel are important I know about:
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Do you currently participate in any structured physical activity?
Yes
No
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If so, please describe type and frequency below:
Your answer
What types of physical activity do you enjoy or have you enjoyed in the past and why?
Your answer
What types of physical activity do you NOT or have not enjoyed in the past and why?
Your answer
What goals can I assist you in reaching in our sessions together?
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What types of activities/assessments are you interested in focusing on in our sessions together?
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What types of activities/assessments are you interested in avoiding during our sessions together?
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Describe the location where you would like to conduct our sessions together. (ex: your apartment gym, your living room, outdoor space, park setting, etc.)
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What day(s)/time(s) are you interested in meeting?
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Any other info you'd like me to know?
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