Embraced Generations LLC
embracedgenerations@gmail.com
www.embracedgenerations.com
(719) 396-1275
Prices
$90/ initial assessment
$70/ 60 min session
$50/ 30 min session
new client Details:
Full Name
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First Name
Last Name
Phone Number
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E-mail
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example@example.com
How did you hear about this training?
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Please Select
Social Media
Google Search
Friend Recommendation
Other
Please Specify
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Will you be willing to recommend this training if you enjoyed it?
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Yes
No
Maybe
Has your provider ever said that you have a heart condition that impacts your ability to exercise?
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yes
no
Do you feel pain in your chest when you perform physical activity?
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yes
no
In the past month have you had pain in your chest when exerting yourself physically?
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yes
no
Do you lose balance because of dizziness or do you ever lose consciousness?
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yes
no
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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yes
no
Are you currently prescribed any medication for blood pressure or a heart condition?
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yes
no
Have you been cleared for exercise by you primary care provider?
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yes
no
Are you currently prescribed any medication for blood pressure or a heart condition?
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yes
no
Have you ever fallen on your tailbone?
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yes
no
How is your bladder working?
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Do you feel that you can empty your bladder?
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yes
no
Do you have to push to empty?
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yes
no
How many times a day do you pee?
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How long is your stream?
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Is it steady?
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yes
no
What are your bowel movements like in relation to the Bristol chart?
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How many times a day do you poop?
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Do you strain when you poop?
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yes
no
sometimes
Do you feel that you can empty your rectum?
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yes
no
sometimes
Do you feel heaviness in your pelvis?
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yes
no
sometimes
Do you ever feel like something is "falling out"?
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yes
no
sometimes
Are you having intercourse?
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yes
no
Any pain in the pelvis in general?
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yes
no
Any surgeries?
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yes
no
Are you currently exercising?
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yes
no
If yes, what are you doing to exercise?
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How many full term births have you had?
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0
1
2
3
4+
N/A
Have you had a baby in the last two years?
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yes
no
If answered "yes" to question above, when did you give birth? (type "N/A" if not applicable)
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How did you birth your baby? (vaginal, cesarian, unmedicated, with an epidural etc)
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Was there any tearing during your birth?
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yes
no
not sure
N/A
Tell me a bit about your birth experience. How long was your labor and pushing time? Did you perceive it as traumatizing, empowering, peaceful etc? Please share as much as you feel comfortable to.
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Are you currently showing any signs of prolapse?
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yes
no
not sure
N/A
Did you have abnormal postpartum bleeding?
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yes
no
N/A
Do you currently have hemorrhoids?
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yes
no
Do you leak when you laugh, cough, sneeze, jump, or run?
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yes
no
To what extent have you sought help for your current issues?
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Has your posture caused issues?
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yes
no
Are you currently breastfeeding?
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yes
no
What are your current goals for personal training?
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How many days a week are you looking to train?
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What times of day typically work for you?
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