Santa Monica Family YMCA Personal Training Screening

To ensure that we meet your specific needs and can pair you up with your perfect personal trainer, please answer the questions below to the best of your ability.


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Email *
Name (first & last) *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
What goal(s) are you looking to accomplish? *
What is your exercise experience? *
Required
Preferred day(s) of the week to train? *
Required
Preferred time(s) of the day to train?
Number of sessions per week desired?
HEALTH CONDITIONS: Please answer the following health-related questions by marking "yes" or "no". *
Yes
No
Has your doctor ever said that you have a heart condition and that you should only do physical activities recommended by a doctor?
Do you feel pain in your chest when you do physical activity? Have you experienced chest pain when not doing physical activity in the last month?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for blood pressure or heart condition?
Are you under a doctor’s care for cardiac (heart attack, stroke), pulmonary (lungs, COPD, asthma), or metabolic (diabetes, thyroid, kidney, liver) disease?
Do you know of any other reason why you should not do physical activity?

If you answered “yes” to any of the questions above, please explain:

Note: Answering “yes” does not disqualify you from training, but rather helps us understand what accommodations (if any) you might need during your sessions.

PERSONAL TRAINING AGREEMENT: Please carefully review the terms below and mark your confirmation of each by checking the boxes on the left.  *
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