in person training intake

Name *

First Name

Last Name

Phone

(###)

###

####

Are you a current member of a gym? *

Yes

No

Have you been exercising regularly for the past 6 months? *

Yes

No

Have you ever had a personal trainer? *

Yes

No

In an effort to effectively assist with nutritional planning, some basic health information is asked for within this form. This is voluntary information and you may refuse to fill out certain parts of this form, however, false or incomplete information may pose a threat to your health for which I cannot be responsible. Please feel free to contact me to clarify anything necessary in completing this form. Have you ever been diagnosed with:

Heart Disease

High Blood Pressure

Hypertension

Cancer

HIV/AIDS

Diabetes

Are you:

Pregnant

On any medications

On any medical restrictions

Receiving medical treatment