Bodied By Benzii Personal Training Intake Form

1

Full Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

3

Email* This field is required.

example@example.com

4

Instagram Handle

@username

5

Age* This field is required.

years

6

Height* This field is required.

ft./in.

7

Weight* This field is required.

lbs

8

If you have any diagnosed health problems list the condition(s).

9

If you are on any medications, please list them.

10

If you have any injuries, please list them.

11

Are you a current cigarette smoker or tobacco user?* This field is required.

Yes

No

12

Do you enjoy alcohol occasionally?* This field is required.

Yes

No

13

What following goals does best fit in with your goals?* This field is required.

Improved health

Improved endurance

Increased strength

Increased muscle mass

Fat loss

Weight Gain

14

Are you currently exercising regularly (at least 3x per week)?* This field is required.

Yes

No

15

Have you trained with a personal trainer before?* This field is required.

Yes

No

16

If so, what kind of training did you do?

17

At what times during the day would you prefer to train?* This field is required.

Morning

Mid-Day

Afternoon

Evening

18

What part of the city would you like to train?* This field is required.

Wayne Junction (Germantown/North Philly)

Fairmount/Brewerytown

Overbrook/Millbourne (West Philly)

Westville, NJ

I would like you to be my travel trainer and come to me!

I am interested in Online Training!

19

What membership plan are you looking for?* This field is required.

Month to Month

Bundle Deal (3,6,12 month deals)

Bodied Bestie Membership (2 people)

20

1.) SCHEDULING

A representative from 'Bodied By Benzii' will reach out within 24 hours for confirmation of intake form and scheduling of first free session.

2.) FEES AND PAYMENTS

50% of chosen memberhship package is due within 48 hours upon completion of first free session. After 48 hours, the potential client will be moved to the "wait list".

3.) 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.

21

I AGREE TO THE ABOVE TERMS & CONDITIONS!* This field is required.

Yes

No