Jump Labs Client Intake Form

Client Training Questionnaire
Part 1. Basic information
Full Name

First NameLast Name
Gender

Other
Date of Birth

MonthDayYear
Contact Number
Mob
Email
Part 2. Current Situation
On a Scale of 1 - 10, how ready are you to change?
What best describes your current exercise goals? (Select all that Apply)

Other
What's been stopping you from achieving these goals?
Are you currently exercising regularly?
Have you trained with a personal trainer before?
What kind of training did you do?
Describe yourself in 3 words!
Part 3. Lifestyle Information
What do you do for a living?
Whats the activity level at your job?
Please list the physical activities that you participate in outside of the gym and work.
Part 4. Medical and Health Information
If you have any diagnosed health problems, please list the condition(s).
If you are on any medications, please list them.
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Has anyone of your immediate family developed heart disease before the age of 60?
Do any diseases run in your family?
Do you suffer from diabetes, asthma, high or low blood pressure?
Please list:
Please Read The Following Terms and Conditions
1.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!
Should be Empty:

Client Training Questionnaire

Part 1. Basic information

Part 2. Current Situation

Part 3. Lifestyle Information

Part 4. Medical and Health Information

Please Read The Following Terms and Conditions