Personal Training Intake Form

Contact Information

Your Name

Pronouns
shehetheyherhimother

Date of Birth

Phone

Email

Instagram Handle

Occupation

Emergency Contact Name & Phone Number

Medical History

Are you currently taking any medications or health supplements? Please specify type, dosage, and reason for taking.

Do you have any allergies?

Do you have a (family) history of heart trouble, high blood pressure, asthma or diabetes?

Have you been hospitalized for any reason? If so, please explain.

Have you ever experienced any head injuries? (Concussion/physical altercations/contact sports/falls/bicycle accident)? If yes, please explain.

Have you ever experienced any problems with sleep? If yes, please explain.

Describe any past or current musculoskeletal conditions you have incurred (surgeries, muscle strains, sprains, fractures, scars, pain, braces, orthotics, general discomfort).

Do you have any other medical conditions that have not been mentioned so far?

Health & Fitness

How would you describe your overall physical health?

How would you describe your daily activity level (intense/moderate/sedentary)? Why?

What degree of stress are you under on a scale of 1-10 (10 is highly stressed, 1 is not stressed at all)? Why?

Do you currently follow a specific nutrition plan or way of eating? If yes, please explain.

Is there any reason, not mentioned above, that you would be limited or unable to participate in any physical activity? If yes, please explain.

Developing your Program

On a scale of 1-10 (1 being bad and 10 being great) how would you rate your current fitness level? Why?

How often do you take part in physical exercise?

If your participation is lower than you would like it to be, what are the reasons? (ex: lack of interest, illness, injury, lack of time, other)

Have you ever participated in an exercise program before? Which and for how long?

Have you ever played any sports before? What and for how long?

What are your fitness interests and/or favorite activities? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)

Which kinds of fitness activities are your least favorite? (ex: cardio, strength training, mobility/stretching, outdoor activities, other)

What are your fitness goals over the next 3 – 12 months? (ex: develop strength, build muscle, lose body fat, increase conditioning, rehabilitate an injury)

How long have you been thinking of these goals?

How important are these goals to you?

If you achieved these goals, how would you feel?

Realistically, how much time are you willing to dedicate to this process?

How much time are you able to spend on this process?

What are the best days/times during the week for you to commit to your fitness program?

Our Coaching Relationship

Why do you want to work with a personal trainer?

Describe your ideal coaching relationship. What is a coach's role is in your fitness journey?

How can I help you reach your goals?

List what you feel are the obstacles or potential actions, behaviors or activities that could stand in the way of accomplishing your goals?

Anything else you’d like me to know about you? Personality? Needs? Core values? Anything that would help me get a better sense of YOU is encouraged!

Acknowledgment, Participant Release & Cancellation Policy

I understand and agree that it is my responsibility to inform Fit With Lou of any condition or changes in my health that might affect my ability to complete the program safely.

I agree that Fit With Lou shall not be liable or responsible for any injuries to me resulting from my participation in the program and I expressly release and discharge Fit With Lou from all claims, actions or judgments as a result of any injury or damage which may occur in connection with my participation.

I understand that Fit With Lou operates on a scheduled hourly appointment basis and that I must provide a minimum of 24 hours notice if I need to reschedule an appointment. The ability to reschedule depends on the availability of open sessions in the following 7-day period after the cancelled session. Where less than 24 hours notice is given, I understand that rescheduling will not be possible and I will be charged for the session. My coach will utilize that time to further develop my training plan.

Upon beginning the program, the contract will automatically renew on a month-to-month basis. I agree to give a notice of one calendar month for cancellation via email to hello@withlou.com in order to cancel the contract.

By signing below, I confirm that all information I submit is correct to the best of my knowledge and that I have read and understood the participant release and cancellation policies.

Signature