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Polyhealth Training - Client Intake Form
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* Indicates required question
Name:
*
Your answer
E-mail:
*
Your answer
Phone:
*
Your answer
Age:
*
Your answer
Gender
*
Choose
Male
Female
Medical Conditions
*
Your answer
Are there any injuries we should know about?
*
Your answer
Goals
*
Your answer
Fitness Background
*
Your answer
Current Exercise Plan (What do you feel it is lacking?)
*
Your answer
How would you best describe your gym facility/gym facilities?
Commercial Gym (i.e. motion fitness, Goodlife)
Cross Fit Gym
Strength and Conditioning Facility
Home Gym
Other:
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What kind of equipment do you have access to?
*
Barbells
Dumbbells
Cable Machines
Resistance Bands
Commercial Gym Machines (i.e. leg press, leg extension)
Stationary Bike
Elliptical
Rower
Medicine Balls
Squat Rack/Combo Rack
Adjustable Benches (incline or flat)
GHR
Required
Motivation
*
1
2
3
4
5
6
7
8
9
10
How did you hear about us?
Your answer
Is there anything else to note?
Your answer
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