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Pre-Consultation Form
Please fill out this form to schedule your consultation with a UHealth Wellness personal trainer. For more information on our wellness offerings, please visit
http://wellness.med.miami.edu
.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone number(s)
*
Your answer
Do you have an active membership at UHealth Fitness and Wellness Center?
Yes
No
Clear selection
University affiliation
*
Choose
Student (Undergrad)
Student (Grad)
Student (Medical)
Faculty
Staff
JMH
Alumni
Spouse/Dependent
Partner
Community
Other
What are your current exercise habits?
*
They don't exist (yet!).
I walk or exercise when I can, but not consistently.
I exercise consistently but I need something new.
Other:
Required
List your short term fitness goals (3 months or less)
*
Your answer
List your long term fitness goals (3 months or more from now)
*
Your answer
What challenges are you facing regarding exercise and wellness? Select all that apply.
*
I have not exercised before.
I don't have the right fitness equipment available to me.
Too many distractions at home.
COVID-19 gym closures affected my progress.
I want a more personalized workout than what I get in virtual group classes.
I don't have the time.
I feel unmotivated.
Other:
Required
Please acknowledge if you have any of the following cardiovascular diseases:
Cardiac disease
Peripheral vascular disease
Cerebrovascular disease
Metabolic disease
Type I diabetes
Type II diabetes
None of the above
Other:
Are you currently managing a chronic condition or pain that your trainer should know about?
*
Yes
No
Other:
If you answered "Yes" to the previous question, please provide more information:
Your answer
Do you have a gender preference for the staff providing your consultation?
*
Male
Female
No preference
Are you interested in Virtual Personal Training or In-Person Personal Training?
Virtual
In-Person
Not sure
Clear selection
If you would like to provide us with additional information or if you have any questions, please include it here:
Your answer
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