Online Training New Client Form
This information will remain secure, and is essential for your training. Please answer everything accurately and to the best of your ability. THIS FORM IS FOR ONLINE TRAINING ONLY.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birth Date
*
/
Month
/
Day
Year
Date
Height
*
Weight
*
(lbs)
Behavior Background
Do you drink alcohol?
*
Please Select
Yes
No
if yes, how often?
Do you smoke?
*
Please Select
Yes
No
If yes, how often?
On average, how many hours of sleep do you get each night?
*
Occupation
Does your job require you at a desk most of the day, or is it active?
*
Please Select
Sedentary
I move around a lot
How often do you eat out a week?
*
Health Background
Did you have any previous major surgeries?
*
Please Select
Yes
No
If yes, please list all
Have you had any previous or current injuries, or pain you may be feeling?
*
Please Select
Yes
No
If yes, please list all
Do you or your family have any history of chronic disease?
*
Please Select
Yes
No
If yes, please list all
Have you ever been diagnosed with any chronic disease?
*
Please Select
Yes
No
If yes, please list all
Are you currently taking any medications?
*
Please Select
Yes
No
if yes, please list all
Goals
Health and Fitness Related
Primary Workout Location
*
Gym
Home
Name of Gym (if applicable)
What are your health related fitness goals, if any?
*
What are your performance goals (perform a pull-up, increase squats, etc), if any?
*
What body composition goals do you have (increase lean muscle mass, decrease waist size, etc)?
*
THANK YOU!
Please check your email within 24-48 hours for a response to your inquiry. Bailey will be emailing you to set up a 15 minute consultation call before you begin!
Submit
Should be Empty: