Intake Questionnaire

Please fill out the below new client questionnaire so I can learn more about your individual fitness needs before our session. Once submitted I will email you to set up a complimentary fitness assessment.

Client Information

Name *

First

Last

Email *

Phone *

Birth Date *

Height *

Weight *

Gender *

Home Address *

Address Line 1

City

State

Work Address

Address Line 1

City

State

Emergency Contact #1 Name *

First

Last

Emergency Contact #1 Relationship *

Emergency Contact #1 Phone *

Emergency Contact #2 Name *

First

Last

Emergency Contact #2 Relationship *

Emergency Contact #2 Phone *

Health Questionnaire

Do you have a heart condition? (Diseased vessels, structural problems, blood clots) *

Have you experienced a stroke? (Blocked artery, leaking or bursting of a blood vessel) *

Do you have epilepsy? (Disorder in nerve cells in brain causing seizures) *

Are you pregnant? *

Do you have diabetes? (High blood sugar) *

Do you have emphysema? (Lung condition that causes shortness of breath) *

Do you feel pain in your chest when you engage in physical activity? *

Do you have chronic bronchitis? (Inflammation, coughing up thickened mucus and shortness of breath) *

In the past month, have you had chest pain when you were not doing physical activity? *

Do you ever lose consciousness, or do you ever lose control of your balance due to chronic dizziness? *

Are you currently being treated for a bone or joint problem that restricts you from engaging in physical activity? *

Has a physician ever told you or are you aware that you have high blood pressure? (A condition in which the force of the blood against the artery walls is too high) *

Has anyone in your immediate family (parents/brothers/sisters) had a heart attack, stroke, or cardiovascular disease before age 55? *

Has a physician ever told you or are you aware that you have a high cholesterol level? (High amounts of cholesterol in the blood) *

Do you smoke? *

Do you drink? *

How often do you drink? *

Are you currently experiencing less than one hour of exercise per week? *

Are you currently taking medication? If yes, please list medication and its purpose below. *

Medication & Purpose

Are you taking vitamins or supplements? If yes, please list below. *

Vitamins/Supplements

Surgery /Other Injuries: *

Any special considerations or how your injury currently affects your ability to function: (i.e. illness or injury) *

Training Questionnaire

What time of the day works best for you for training? *

Mornings
Afternoons
Evenings

What are your concerns and goals? (Examples: fat loss, strength, power, endurance, cardio fitness, flexibility, agility, core stability or balance) *

What areas do you want to concentrate on or emphasize? *

How long has it been since you exercised regularly? (2 or more times per week) *

Do you have experience with free weights and cardiovascular exercise? *

Additional comments

Checkboxes *

I have read and agree to the Release of Liability.

Checkboxes (copy) *

I have read and agree to the Personal Training Agreement.

Captcha *

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Comment

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Intake Questionnaire

Client Information

Health Questionnaire

Training Questionnaire

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