Personal Training Intake Form
Please answer all questions with as much relevant information as possible. This helps Jordynn in creating a valuable program that works for you. All information will be kept confidential.
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Name: *
Email: *
Date of birth: *
Physical Activity Readiness: (Check all that apply - If you have answered YES to one or more of the below questions, consult your physician before engaging in physical activity.)
Medical: please list and explain all injuries, pain, surgeries, chronic diseases & medications below. *
Occupational: please describe your occupation, any repetitive movements or prolonged sitting/standing and mental stress. *
Recreational: please share what you like to do for recreational physical activities and additional hobbies (golf, running, gardening, reading, etc.) *
Where you are now: Rate the quality of your sleep (on average). *
Poor
Great
Where you are now: Rate your mental stress. *
Low
Very High
Where you are now: What is your current exercise routine? *
Where you want to go: What are your fitness goals? Be specific. *
How to get there: Will you be working out at home, in a gym or somewhere else? What equipment/space do you have access to? *
How to get there: How often & what length of time can you commit to your fitness routine? Be realistic. *
Is there anything else you'd like to share with me?
Please list 5 date/time options you are available for your free 20 minute consultation. *
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