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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:
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Your answer
Email:
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Your answer
Date of birth:
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Your answer
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.)
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?
Medical: please list and explain all injuries, pain, surgeries, chronic diseases & medications below.
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Your answer
Occupational: please describe your occupation, any repetitive movements or prolonged sitting/standing and mental stress.
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Your answer
Recreational: please share what you like to do for recreational physical activities and additional hobbies (golf, running, gardening, reading, etc.)
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Your answer
Where you are now: Rate the quality of your sleep (on average).
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Poor
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Great
Where you are now: Rate your mental stress.
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Low
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Very High
Where you are now: What is your current exercise routine?
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Your answer
Where you want to go: What are your fitness goals? Be specific.
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Your answer
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?
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Your answer
How to get there: How often & what length of time can you commit to your fitness routine? Be realistic.
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Your answer
Is there anything else you'd like to share with me?
Your answer
Please list 5 date/time options you are available for your free 20 minute consultation.
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Your answer
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