Fitness Programming Intake Form

Full Name

Date of Birth

Email Address

Phone Number

Emergency Contact Full Name

Emergency Contact Phone Number

Health History

Have you been cleared by a doctor to participate in physical exercise?

Yes I've been cleared

No I haven't received clearance

Do you have any current or past injuries, surgeries, or medical conditions? (e.g., back pain, knee issues, high blood pressure). If yes, please explain

Are you currently taking any medications? If yes, please list

Do you have any chronic pain or areas of discomfort? If yes, please describe

Do you experience any of the following during physical activity? (Check all that apply)

Shortness of breath

Chest pain

Dizziness or lightheadedness

None of the above

Exercise History

How would you rate your current fitness level?

Low (0-2 times a week)

Moderate (3-4 times a week)

High (5+ times a week)

What is your interest level with the following types of exercise?

Please rate each option on a scale of 1 to 5 (1 being low interest, don’t want to do it, 5 being I love doing it).

Cardio (e.g., running, cycling)

Strength training (e.g., weightlifting, free weights, machines)

Calisthetics (e.g., bodyweight, no/minimal equipment workouts)

Yoga or Pilates

Mobility or flexibility exercises

High-Intensity Interval Training (HIIT)

Sports or other (Please specify)

Are there any exercises or movements you’re uncomfortable doing or unable to perform? If yes, please describe

Do you have a regular exercise routine? If yes, please describe your current routine, including frequency and duration)

What types of exercise or training have you enjoyed in the past?

Lifestyle

How many hours per week can you commit to exercising?

What is your occupation, and does it involve prolonged sitting, standing, or heavy lifting?

How many hours of uninterrupted sleep do you get on average?

Do you wake up feeling rested?

Do you smoke, vape, or consume alcohol? (If yes, please specify what you consume and the frequency)

Goals and Preferences

What would you rate the importance of the following fitness goals?

Please rate each option on a scale of 1 to 5: (1-5, 1 least important, 5 very important/priority).

Weight loss

Muscle gain

Improved flexibility/mobility

Increased endurance

Improved strength

Pain management/reduction

Stress relief

Other (please specify what and rate importance)

How many workouts a week do you want to do?

Do you have any specific short-term (3-6 month) goals (e.g., preparing for an event, wedding, vacation)?

Do you have any specific long-term (6-12 month) goals (e.g., preparing for an event, wedding, vacation)?

Is there anything else you’d like me to know about your health, fitness, or preferences?

Once you have hit submit on your intake form, you will be redirected to a liability waiver to fill out.

AUTHENTIC MOVEMENT CO.

HOME

1:1 COACHING

SKOOL COMMUNITY

CONTACT

HOME

1:1 COACHING

AUTHENTIC MOVEMENT CO.

SKOOL COMMUNITY

CONTACT