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Your Strength New Client Interview & Liability
Thank you for your interest in training with me.
Lets get to know you.
Each individual who participates in coaching from Your Strength must complete their own Pledge, Release and Registration.
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Email
*
Your email
Name
*
Your answer
Occupation
*
Your answer
DOB
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MM
/
DD
/
YYYY
Emergency Contact Name/ Phone #
*
Your answer
How did you hear about me?
Your answer
Are you taking any medications? * If yes, please list name and use:
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Your answer
Are you currently pregnant?* If yes, how far along?
*
Your answer
Medical Conditions & history. Including surgeries in the 5 years and any joint surgery at any time. Please include regular pain or weakness issues you notice.
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Your answer
What is your primary health/fitness/lifestyle goal at this time?
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Your answer
Are you currently working with a Physical Therapist at this time?
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No
Yes
Other:
Do you have any pelvic floor or breathing concerns?
*
Yes
No
Unsure
Do yo have orthopedic issues?* If yes please explain
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Your answer
Do you have any of the following?
*
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement
High/low blood pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or strains
None
Required
Please further explain anything you have checked above.
Do you have any other conditions not listed?
*
Your answer
Do You have allergies or sensitives?
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Your answer
Do you suffer from chronic pain?* If yes, please tell me about it.
*
Your answer
How many days per week do you want to train with me?
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1 x's per week
2 x's per week
3 x's per week
4 x's per week
Required
What days of the week?
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Monday
Tuesday
Wednesday
Thursday
Friday
Other:
Required
Time of day you would like to workout?
*
early morning
mid morning
early afternoon
late afternoon
evening
Required
What are your short term (3-6 month) health/fitness/lifestyle goal at this time?
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Your answer
What are your long term (6 month+) health/fitness/lifestyle goal at this time?
Your answer
Are there any exercises or movements you are uncomfortable performing?
Are there any exercises or movements you that are your favorite
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Your answer
How would you rate your current fitness level? 1- Newby, 10- Pro athlete
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Newby
1
2
3
4
5
6
7
8
9
10
Pro athlete
What are you looking for from me as a coach?
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Motivation
Accountability
Expertise
Rehab/corrective exercise/ post PT help
other*
Required
If you marked other above, please explain
Your answer
Have you ever worked with a coach before? Please tell me about that experience.
*
Your answer
How excited are you to start this journey?
*
Meh
1
2
3
4
5
The most ready I've been ever!
Are you interested in an online/ in person hybrid training program? Now or in the future?
Yes
No
Maybe
Clear selection
Do you foresee any potential obstacles between you and your goals?
*
Your answer
How do you want to communicate?
*
Text
Email
Phone
Required
Please add your phone number for text/ phone communication.
*
Your answer
What is your favorite type of music or artist?
*
Your answer
Do you have any questions for me?
Your answer
Would you like to be subscribed to my mailing list for occasional updates, specials, events, and education?
*
yes
no
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