Client Intake Form Template for Senior Fitness

Use in FirstRep form

Personal Information

Collecting basic personal details helps tailor the fitness program to individual needs.

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

Health History

Understanding your health history is crucial for safe exercise planning.

Y/N Do you have any chronic conditions? *

... List any chronic conditions

e.g., diabetes, arthritis

Y/N Have you had any surgeries? *

... List any recent surgeries

e.g., hip replacement

Medication Information

Knowing your medications helps avoid exercise-related complications.

Y/N Do you take any medications? *

... List your medications

e.g., blood thinners, pain relievers

Y/N Do you have concerns about medication interactions with exercise?

Fitness Goals

Setting clear fitness goals helps in tracking progress and motivation.

... What are your fitness goals? *

e.g., improve balance, increase strength

# How many days per week do you plan to exercise? *

Enter number of days

vv What activities do you enjoy? *

Exercise Experience

Understanding your previous exercise experience helps in customization.

Y/N Have you exercised regularly in the past? *

... Describe your previous exercise routine

e.g., types of exercises, frequency

Y/N Do you have any concerns about starting an exercise program? *

Support System

Identifying your support system can enhance accountability and motivation.

Y/N Do you have a caregiver or someone who supports your fitness journey? *

Aa Who is your main support person?

Enter their name

v How do you prefer to communicate with your support system? *

Why Use This Template

Personalized Approach

Understanding individual health needs leads to safer and more effective exercise programs.

Goal Setting

Helps clients articulate their fitness goals, which can improve motivation.

How to Use

Fill out the form completely to provide a comprehensive overview of your fitness needs.

Consult with your healthcare provider if you have any concerns about your health and exercise.

Customization Tips

Tailor questions based on specific chronic conditions common in seniors.
Include resources for caregivers who are filling out the form.
Offer examples of fitness goals that relate to improved independence.

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

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Frequently Asked Questions

What if I have health concerns?

Always consult with your healthcare provider before starting any new exercise program, especially if you have health issues.

Can I fill this form out for someone else?

Yes, caregivers are encouraged to fill out the form for seniors who may need assistance.