Body By Wayne Client Intake & Tracking forms Complete Package of all 5 Body By Wayne Custom Client Forms. "Complete Fitness Profile, Assessment, Goal, & Nutrition Tracking Forms"

1. FITNESS ASSESSMENT QUESTIONAIRE
PLEASE ANSWER ALL QUESTIONS ACCURATELY & HONESTLY ALOWING US TO FULLY DETERMINE YOUR INDIVIDUAL NEEDS
First Name Last Name Prfd. Name:
Primary Phone Business Phone
E-Mail News Letter Yes No
Age Height Weight Ideal Weight
In terms of my health and fitness I would like to:
▢Lose Weight ▢Gain Weight ▢Look Better ▢Feel Better ▢Other (Specify Below)
What specific areas would you like to target for improvement?
Is there something happening in your life that you want to look or fee particularly good for?
How long have you been thinking about beginning or getting back on a regular fitness program?
Over the past 10-years, how many times have you started and stopped a nutrition and/or fitness program?
▢1-5 ▢6-10 ▢11-15 ▢16-20 ▢Too Many to Count
What external factors have derailed your progress in the past?
▢Time ▢Money ▢No Facility ▢Procrastination ▢Lack of Support
In your own opinion, why did you fail to “stick with it”?
▢Discipline ▢Knowledge ▢Experience ▢Accountability ▢Lack of Expertise
Have you thought about how much time you are willing to commit to exercising in order to reach your goals? Y N
If yes, about how much time will you be dedicating to your fitness goals:
Who will be supporting your efforts to achieve your goals?
Do you have any poor health habits you would like to change? Y N If yes, please explain
When was the last time you were in the shape you want to be in?
What Dress/Pants size were you then? Now?
How did you feel?
On a scale of 1-10, (10 being highest) how serious are you about achieving your goals?
1 2 3 4 5 6 7 8 9 1 0
Are there any conditions (health or physical) your trainer should be aware of? Please be very specific. Use the backside of this
page to explain if necessary.
OFFICE USE ONLY:
Appointment Day: Date: Time: AM PM
Client Phone: Client Email: 24-HR Reminder Sent ▢
Body Fat%: Ideal Body Fat%: Weight: Ideal Weight:
CLIENTS ACKNOLEDGEMENT AND ASSUMPTION OF RISK AND FULL RELEASE OF LIABILITY OF BODY BY WAYNE: Client acknowledges that
the Personal Training/Fitness Assessment hereunder includes participation in strenuous physical activities, including but not limited to aerobic
dance, weight training, stationary bicycling, various aerobic conditioning machines, various weight training and strength building equipment, and
various nutritional programs “Physical Activities” offered by Body By Wayne. Client acknowledges these physical activities involve inherent risk
of physical injuries and other illness, soreness, or injury however caused, occurring during or after the clients participation in physical activities.
Client further acknowledges that such risks include but are not limited to, injuries cause by negligence of an instructor or other person, defective
of improperly used equipment, over exertion of a client, slip and fall by client, or any known health problems of client. Client agrees to assume
all risk and responsibility involved with participation in the physical activities. Client also acknowledges participation will be physically and
mentally challenging, and Client agrees that is the responsibility of Client to seek competent medical or other professional advice, regarding any
concerns involved with the ability of Client to take part in Body By Wayne Physical Activities. By signing this agreement, Client asserts that
he/she is capable of participating in physical activities. Client agrees to assume all risk and responsibility for not exceeding his or her own
physical or mental limits. Client on behalf of client his or her heirs, assigns, and next of kin, agrees to fully release and hold harmless Body By
Wayne and/or owners, trainers, staff, or other authorized agents, signers, and successors including independent contractors, investors, and
volunteers, from any and all liability claims and/or litigation actions that Client may have for injuries, disability, death, or damages of any kind
including but not limited to punitive damages, arising out of participation in Body By Wayne personal training and/or physical activities and/or
nutritional activities and programs; even if caused by gross negligence, intentional acts or omissions and/or any other type of fault of Body By
Wayne and/or owners, trainers, staff, or other authorized agents, signers, and successors including independent contractors, investors, and
volunteers. By signing below I hereby state I have read and fully understand and agree with this release of liability.
Client Signature: Date:
Client Printed Name:

2. Body By Wayne
PT1 Date:
PT2
FITNESS ASSESSMENT
NAME: AGE: HEIGHT: WEIGHT: BODY FAT:
BICEPTS:
TRICEPTS:
SUBSCAP:
SUPRA ILIAC:
PHYSICAL ACTIVITY READINESS
ARE YOU CURRENTLY TAKING ANY MEDICATIONS (PERSCRIPTION OR OVER-THE-COUNTER)? YES NO
IF YES, DESCRIBE/EXPLAIN:
DO YOU HAVE ANY BONE OR JOINT PROBLEMS? YES NO
IF YES, PLEASE DESCRIBE:
DO YOU HAVE ANY PHYSICAL CONDITIONS THAT MAY BE AGGRIVATED BY AN INCREASE IN PHYSICAL
ACTIVITY (HEART PROBLEMS, ASTHMA, OR HIGH BLOOD PRESSURE)? YES NO
IF YES, PLEASE DESCRIBE:
EXERCISE HISTORY
WHAT ACTIVITIES ARE YOU CURRENTLY PARTICIPATING IN?
HAVE YOU BEEN A MEMBER WITH A GYM BEFORE? YES NO
HAVE YOU HAD A PERSONAL TRAINER BEFORE? YES NO
WHAT ACTIVITIES (WEIGHT TRAINING, CARDIO, SPORTS, ETC.) HAVE YOU PARTICIPATED IN PREVIOUSLY?

3. Name: Date:
Address:
State Zip
Email: Newsletter Yes No
Is there someone we can thank for reffering you? Yes No Who:
YES NO
X = Yes
How long have you been thinking about your goals?
On a scale of 1-10 how serious are you?
How many times per week do you pan to exercise?
Put into words what your visualization of a picture of your perfect health, what would it be?
Guest Signature Guest Printed Name
If not a current client, how did you hear about Body By Wayne?
ACCIDENT/INJURY: Guest(s) herby represents that he/she is in sound physical condition and expressly agrees that all exercises and all
use of all facilities and equipment shall be undertaken at the guest's own personal risk and that the company and/or it's affiliates, signors, and
successors ahsll in no way be liable for any claimes or demands arising our of the guest's use of company facilities.
Primary Phone: Business Phone:
Street City
Goal Timeframe How Much Why
Lose Weight
Cadiovascular Conditioning
Injury Details: What type of injury? When did the injury occur?
Increase Muscular Size
Reduce Stress
Tone & Firm Lean Muscle
Increase Strength
Body By Wayne
EXERCISE HISTORY
Reduce Stress
GOALS
For what reason did you end your previous workout?
Where did you work out?
GOAL PLANNING
Other:
Have you ever had a membership with a fitness club?
When was the last time you worked out?
Fitness
Basketball
Gain Weight
What do/did you usually do when you exercise?
What is the most important area of a fitness club to you?

4. Name: Date:
What are your primary fitness goals?
Other Goals:
Why?
Breakfast Time: What:
Snack Time: What:
Lunch Time: What:
Snack Time: What:
Dinner Time: What:
Snack Time: What:
NOTES:
What time of day will you be exercising?
Days For:_____________ to Minutes
Per Week
NOTES:
Fee Weights Bands
Fulll Body Upper Body 1-2 Muscle Groups 2-3 Muscle Groups
WORKOUTS
1 2 3 4 5 6 7Cardiovascular Exercise
1 2 3 4 5 6 7How many days per week does exercise fit into your lifestyle?
EXERCIZE RECOMMENDATIONS
What if any, vitamins or suppliments are you taking?
Other Fluids?How many glasses/bottles (reg. 8oz) of water do you drink daily?
When did you feel that you were in the best shape of your life?
Do you have a timeframe in mind to achieve these goals?
Have you ever participated in a weight loss program?
1 2 3 4 5 6 7 + Other:__________How many times per day do you normally eat?
EQUIPMENT
Circuit Extended Circuit
Body By Wayne
NUTRITION
Hammer Strength
Weight Training 1 2 3 4 5 6 7
CLIENT GOALS

5. Name Day Date
Body By Wayne
Please complete by filling out all applicable & required sections below.
TOTAL:
GRAND TOTAL:
Client Dietary Worksheet
Protien Carbs FatFood & AmountTime