INTAKE FORM Simply answer each question to continue registration. Intake Form What are you signing up for?(Required)What are you signing up for? Personal Training 6 Week Program GENERAL INFORMATIONName(Required) First Last DOB(Required)Date of birth MM slash DD slash YYYY Height(Required)Height Weight(Required)Weight Health Care Provider(Required)Health Care Provider Phone number(Required)Phone numberEmail(Required)Email address Date(Required)Current date MM slash DD slash YYYY LET'S GET MORE PERSONALHas your health care provider ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?(Required)Has your health care provider ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No Please describePlease describe Do you feel pain in your chest when performing physical activity?(Required)Do you feel pain in your chest when performing physical activity? Yes No Have you experienced chest pain when NOT performing physical activity in the last month?(Required)Have you experienced chest pain when NOT performing physical activity in the last month? Yes No Do you lose your balance because of dizziness or have you lost consciousness recently?(Required)Do you lose your balance because of dizziness or have you lost consciousness recently? Yes No Do you have any bone or joint problems (back, knee, hip, etc.) such as arthritis, which could be aggravated through physical activity?(Required)Do you have any bone or joint problems (back, knee, hip, etc.) such as arthritis, which could be aggravated through physical activity? Yes No Please describePlease describe Is your doctor currently prescribing you medications for high blood pressure or heart condition?(Required)Is your doctor currently prescribing you medications for high blood pressure or heart condition? Yes No Please describePlease describe Are you a diabetic?(Required)Are you a diabetic? Yes No Do you have any injuries that may hinder your physical activity?(Required)Do you have any injuries that may hinder your physical activity? Yes No Please describePlease describe Is there any reason why you should not participate in physical activity?(Required)Is there any reason why you should not participate in physical activity? Yes No Please describePlease describe Do you have any diseases that may hinder you from working out?(Required)Do you have any diseases that may hinder you from working out? Yes No Please describePlease describe Do you have an autoimmune disease?(Required)Do you have an autoimmune disease? Yes No Please describeWhich one? Are you currently pregnant?(Required)Are you currently pregnant? Yes No Are you currently trying to get pregnant?(Required)Are you currently trying to get pregnant? Yes No Have you given birth?(Required)Have you given birth? Yes No Have you experienced abdominal separation?(Required)Have you experienced abdominal separation? Yes No Have you ever experienced any hormonal imbalances?(Required)Have you ever experienced any hormonal imbalances? Yes No If female, are your menstrual cycles regular? Irregular?If female, are your menstrual cycles regular? Irregular? Regular Irregular Are you currently taking any vitamins or supplements?(Required)Are you currently taking any vitamins or supplements? Yes No Please describeWhich ones? Do you currently exercise on a regular basis (3+ times per week)?(Required)Do you currently exercise on a regular basis (3+ times per week)? Yes No Do you plan on losing weight or do you want to maintain your current weight?(Required)Do you plan on losing weight or do you want to maintain your current weight? Lose Maintain Do you feel you need to gain weight?(Required)Do you feel you need to gain weight? Yes No Have you ever experienced any mental issues with diet?(Required)Have you ever experienced any mental issues with diet? Yes No Do you feel you could improve your diet?(Required)Do you feel you could improve your diet? Yes No Do you feel your eating habits are healthy?(Required)Do you feel your eating habits are healthy? Yes No Do you have any dietary restraints?(Required)Do you have any dietary restraints? Yes No Have you ever counted calories or macros?(Required)Have you ever counted calories or macros? Yes No Did you experience any negativity mentally from counting calories or macros?(Required)Did you experience any negativity mentally from counting calories or macros? Yes No Is weighing yourself something that bothers you?(Required)Is weighing yourself something that bothers you? Yes No Do you have a reliable scale?(Required)Do you have a reliable scale? Yes No Have you ever measured yourself?(Required)Have you ever measured yourself? Yes No Would you be able to measure yourself or allow me to measure you?(Required)Would you be able to measure yourself or allow me to measure you? Yes No Where do you prefer to work out?(Required)Where do you prefer to work out? Are online workouts feasible for you?(Required)Are online workouts feasible for you? Yes No Are you able to work out from home?(Required)Are you able to work out from home? Yes No What gym do you belong to?(Required)What gym do you belong to? Is there a gym you are willing to join?(Required)Is there a gym you are willing to join? What time of day do you prefer to work out?(Required)What time of day do you prefer to work out?
