FIT Factor, LLC
Client Intake Form

This form will take about 20 minutes to complete. Please answer all subjects to the best of your ability. 

 
 
CLIENT INTAKE
General information section Part 1/8
Name *
Name
Gender *
Date of Birth *
Date of Birth
Phone *
Phone
Text friendly? *
Preferred method of contact *
Address *
Address
Physician name *
Physician name
Physician phone number *
Physician phone number
Emergency contact *
Emergency contact
Emergency contact (phone) *
Emergency contact (phone)
Training package selected *
MEDICAL HISTORY FORM
Please fill this out to the best of your ability. The more information I receive, the better I can customize your program to meet your needs. Part 2/8
Are you currently under a doctor's care? *
When was the last physical examination you had? *
When was the last physical examination you had?
Have you ever had an exercise stress test? *
Do you take any medications? *
Have you been recently hospitalized? *
Have you had any surgeries? *
Do you smoke? *
Do you drink alcohol? *
Is your stress level high? *
Are you moderately active on most days of the week? (please select days that you are) *
Do you have or have had any of the following? *
Do you have have any immediate relatives (siblings, parents, grandparents, aunts, or uncles) that have had any of these conditions prior to age of 55? *
By writing your name below, you (client) acknowledge that you are digitally signing and attesting that to the best of your knowledge, the above medical information is accurate and true. You are also guaranteeing that you will report any new health information to John Wehrer (trainer) as soon as it is available. *
By writing your name below, you (client) acknowledge that you are digitally signing and attesting that to the best of your knowledge, the above medical information is accurate and true. You are also guaranteeing that you will report any new health information to John Wehrer (trainer) as soon as it is available.
Today's date *
Today's date
EXERCISE HISTORY
Please fill this out to the best of your ability. The more information I receive, the better I can customize your program to meet your needs. Part 3/8
Activity level
Activity level
Please fill all age ranges that apply to you. For reference, "very active" translates to exercising multiple times per week, walking or biking to school/work, etc.
I was/am very active in my teen years
I was/am very active in my 20's
I was/am very active in my 30's
I was/am very active in my 40's
I was/am very active in my 50's
I was/am very active in my 60's
I was/am very active in my 70's and above
How strenuous is your job? *
PROGRAM DEVELOPMENT QUESTIONNAIRE
Please fill this out to the best of your ability. The more information I receive, the better I can customize your program to meet your needs. Part 4/8
Have you worked with a personal trainer in the past? *
Please select the days you generally exercise. *
How would you rate your current activity level? *
Please select the days you are realistically able to exercise. *
Are you currently a member of a gym? *
ATHLETIC PERFORMANCE SECTION
Please only fill this out if you selected a premier package (tier 4) Part 5/8
What is the date of your event that you training for?
What is the date of your event that you training for?
Do you have a heart rate monitor?
Do you have a good understanding of the RPE scale?
TERMS AND CONDITIONS
Please read all Terms and Conditions here: https://www.my-fitfactor.com/terms-conditions Part 6/8
I have read the above terms and conditions, and understand what is expected. I hereby, agree to the above terms and conditions. By typing my name below, I acknowledge and agree to the above statements. I agree that typing my name will act in place of my written signature. *
I have read the above terms and conditions, and understand what is expected. I hereby, agree to the above terms and conditions. By typing my name below, I acknowledge and agree to the above statements. I agree that typing my name will act in place of my written signature.
Today's date *
Today's date
ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT
Please read all Terms and Conditions here: https://www.my-fitfactor.com/waiver/ Part 7/8
I have read and understand the above assumption of risk, waiver, release of liability, and indemnity agreement. By typing my name below, I acknowledge and agree to the above statements. I agree that typing my name will act in place of my written signature. *
I have read and understand the above assumption of risk, waiver, release of liability, and indemnity agreement. By typing my name below, I acknowledge and agree to the above statements. I agree that typing my name will act in place of my written signature.
Today’s date *
Today’s date
REFERRAL PROGRAM
Every person you refer that purchases at least one month of training, you will receive 1 free month of training. So, if you refer 12 people, that is an entire year of training, completely paid for!! Please have each person you refer put your name on the intake form! Part 8/8