Personal Training Intake Form
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Email *
Email Address *
Please provide your first and last name:
What is the best number to reach you?
When were you born? Month/Date/Year
MM
/
DD
/
YYYY
Who is your personal physician? (phone number)
How many times per week do you engage in physical actiivity?
Day
Days
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What health and fitness goals would you like to accomplish? Be specific
What is a realistic timeframe in which you'd like to achieve your goals?
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Do you feel the assistance from a fitness professional could help you achieve your goals more efficiently, if so how?
Do you personally have a history of any of the following?
Do you have medical approval to participate in this program?
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Are you over the age of 35?
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Are you pregnant?
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Are you on any medications?
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If you answered "yes" to the previous question please list the name of the medication and what it's for:
Do you smoke?
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Do you drink alcohol?
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Do you currently perform regular aerobic exercise? How often?
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I acknowledge, to the best of my ability, that I am in good health and have no known medical problems that would restrict my ability to participate in this exercise program and the continuing and any ongoing personal training session *
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