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INTAKE FORM
GENERAL INFORMATION FORM. FILL OUT COMPLETELY AND THEN SUBMIT
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Physical Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip code
*
Your answer
Cell Phone
*
Your answer
Home Phone
*
Your answer
Birthday
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MM
/
DD
/
YYYY
Age / Weight / Height
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Your answer
How did you hear about Dr Fitness USA?
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Your answer
Occupation
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Your answer
Do you belong to a gym? Name / Address / Zip Code
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Your answer
If not, are you willing to join a gym?
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Yes
No
Other:
Do you have any weight lifting equipment at home?
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Dumbbells
Kettlebells
Bench
Workout bands
Other:
If so, what weight range?
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Your answer
What are you current fitness activities?
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Your answer
What are you past fitness activities?
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Your answer
Goals
*
Lose Weight
Gain Weight
Define Muscles
Tone & Firm
Gain Strength
General Health
General Fitness
Stress Reduction
Correct Postural Alignment
Relieve Back Pain
Other:
Required
Are you currently involved with
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Personal trainer
Cross Fit
Boot camps
Spartan
Pilates
Yoga
Zumba
Other:
Required
How many days a week are you available to train?
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Your answer
When are you ready to start?
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Your answer
Level of priority in improving your health & body
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Least
1
2
3
4
5
6
7
8
9
10
Most
What is your WHY?
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Your answer
Do you have a budget set aside for your health?
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Yes
No
Other:
What is your budget?
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Your answer
Injuries
*
Your answer
Illnesses
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Your answer
Is there anything else we should know about?
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Your answer
Do you want to know more about Dr Fitness USA private mentoring program?
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Yes
No
Other:
Required
Why should Dr Fitness USA consider you in his private mentoring program
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Your answer
Are you coachable?
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Yes
No
Other:
Which of the 3 types below are you?
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I need help, but since I am the client and I am paying you, we will need to do things my way
I need help, but I am expecting you to do all the work
I need help, so tell me what I need to do and I will do it because you are the expert
Other:
By submitting this document you acknowledge that your answers are true
*
Yes
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