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Client Info
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Name
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Birthday
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DD
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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:
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What types of physical activity do you enjoy or have you enjoyed in the past and why?
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What types of physical activity do you NOT or have not enjoyed in the past and why?
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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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