Client Intake Form Template for Fitness for Back Pain

Use in FirstRep form

Personal Information

Essential for understanding your background and specific needs related to back pain.

Aa Full Name *

Enter your full name

# Age *

Enter your age

Aa Email Address *

Enter your email address

Aa Phone Number

Enter your phone number

Medical History

To assess past medical issues that may affect your back pain.

Y/N Have you had any surgeries on your back? *

... Please describe any past injuries related to your back.

Describe past injuries

... Current medications

List your current medications

Pain Assessment

Understanding the specifics of your pain is crucial for creating a tailored program.

1-10 Rate your current back pain on a scale of 1-10. *

D When did you start experiencing back pain? *

Select date

... What activities worsen your pain? *

Describe activities that worsen pain

... What activities relieve your pain? *

Describe activities that relieve pain

Current Activity Level

To gauge your current fitness routine and readiness for exercise.

# How many days a week do you exercise? *

Enter number of days

... What type of exercise do you currently do?

Describe your current exercise routine

... Are there any exercises you avoid?

List any exercises you avoid

Goals and Expectations

Understanding your goals helps tailor the program to your needs.

... What are your main goals regarding your back pain? *

Describe your goals

... What are your expectations from this program? *

Describe your expectations

Referral and Support

To know if you have additional support from healthcare professionals.

Y/N Have you consulted a healthcare professional for your back pain? *

... If yes, please specify their recommendations.

Describe recommendations

Why Use This Template

Understand your client's unique situation

Gathering detailed information allows for tailored solutions.

Build trust and rapport

A thorough intake shows you care about their specific needs.

How to Use

Fill out all required fields to ensure comprehensive understanding.

Be honest about your pain levels and activity to receive the best guidance.

Customization Tips

Add specific questions relevant to your services.
Include a section for client feedback on the form.
Adjust the pain assessment section based on client demographics.

Build and send fitness for back pain templates digitally with FirstRep. Free for up to 3 clients.

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Frequently Asked Questions

What if I have more questions after filling out the form?

Feel free to contact us via email or phone for any additional inquiries.

Is my information confidential?

Yes, all information will be kept secure and confidential.