I start with a PAR-Q followed by limitations ie. (previous injuries, past surgeries, current medications), bodyweight, fat percent, before photos, physicians release, measurements and any other type of restrictions.
My clipboard has an anitomical chart and I point out specific areas of the body we are training and my clients can point out what they want to focus on or the areas they have issues.
I journal every clients daily workout PT session and my client also keeps a journal for their nutrition and training days without me. We review their journal on a weekly basis and re-evaluate with 90 days.