TrueForm Intake Assessment

Wellness Intake Form
Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Height*
Weight*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Part 1: PreScreening Health Assessment

Please answer yes or no to the following 7 questions.
Has your doctor ever said that you have a heart condition and/or that you should only perform physical activity recommended by a doctor?*

YesNo
Do you feel pain in your chest when you perform physical activity?*

YesNo
In the past month, have you had chest pain when you were not performing any physical activity?*

YesNo
Do you lose your balance because of dizziness, or do you ever lose consciousness?*

YesNo
Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

YesNo
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*

YesNo
Do you know of any other reason why you should not engage in physical activity?*

YesNo
If you have answered YES to one or more of the above questions, consult your physician before continuing with this form and before engaging in physical activity. Tell your physician which questions you answered YES to. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. A physical activity medical clearance form is required prior to engaging in training services by TrueForm LLC. Please contact if form is needed.

If you have answered NO to all of the above questions, please continue with this form.
Are you taking any medications and/or supplements?*

YesNo
If yes, please explain
Do you have any allergies or sensitivities to products and/or foods?*

YesNo
If yes, please explain
Have you had any injuries resulting in rehab and/or surgery?*

YesNo
If yes, please explain
Do you have any additional health concerns we should know about?*

YesNo
If yes, please explain
Photo/Video Consent
This authorization grants permission to use your image (still or moving) and/or your spoken words in perpetuity for educational purposes.

By signing this document, you agree:

1. To allow the recording of your image and voice (e.g., photographs, audio, or video).

2. To distribute your image or recording in any medium, be it print or electronic form, which may include the Internet.

3. To grant permission to other entities to reproduce the images or recording for educational purposes.

4. That there is no reimbursement for the right to take, or use your photograph or video or recording.
Do you give TrueForm Nutrition & Fitness consent to use your video and/or photos?*

YesYes, only if my face is not shownNo
Signature

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Before Training Questionnaire
What type of plan have you tried in the past to reach your wellness goals?*

Research & knowledge on my ownFitness apps/programsBootcamps/Fitness classesOne-on-one trainers
Have you ever tried a specific diet approach now or in the past?*

YesNo
If yes, please explain
Did any of the methods mentioned above work for you?*
Are you comfortable with measuring tools? (e.g., Scales, Measuring Tapes, Performance Test, etc.)*

YesNo
What area(s) are you looking to improve on?*

NeckShouldersChestArmsTorsoBackHips & GlutesLegsDigestion
What are your specific fitness & nutrition goals?*
How much water do you drink a day?*
How much sleep do you typically get at night?*
Do you stretch?*

YesNo
What is your current fitness level?*

Little or no exerciseExercise 1-3 times per weekExercise 4-5 times per weekDaily exercise or intense exercise 3-4 times per weekIntense exercise 5-7 times per weekIntense exercise daily, or physical job
Are you ready to gain the tools to look, feel, & find your TrueForm?

YES!No
Refund Policy: Although customer satisfaction is our main priority, we DO NOT offer refunds for completed services OR packages once purchased.

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Transfer Policy: Packages or purchased sessions are NON-TRANSFERRABLE to other services or persons.

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1. Billing agreement: All personal training clients are billed on a pre-pay basis. Bills are issued directly to a client and are due upon receipt before training begins.
2. Length of sessions and appointment times: Each training session is based on a [60 minute] workout, unless appointed otherwise. To get the most out of our efforts, please be ready to exercise at the appointed time. If you are more than 15 minutes late for a scheduled session, it will be considered a no-show and you will be charged normal session price.
3. Online Coaching: Each Strategy Chat/Virtual Session is based on a [30 minute] time frame. To get the most out of our efforts, please be ready to meet at the appointed time. If you are more than 15 minutes late for a scheduled session, it will be considered a no-show and you will be charged normal session price.
4. Cancellation policy: All sessions are arranged on a scheduled appointment basis. For the most effective use of time, all clients are asked to give 24-hour notice when cancelling an appointment. This means a cancellation should be made at least 24 hours before the scheduled appointment by calling or texting TrueForm directly. Personal training, semi private, and online coaching sessions cancelled inside of 24 hours of the scheduled appointment will be billed at the normal rate of a single session and deducted from your account unless a make-up session is completed within 24 hours of scheduled session. A $20 fee will be charged to your account if cancelation/reschedule occurs within 1 hour of scheduled session. If arriving late for a session, the scheduled time frame will remain the same and at the scheduled rate.
5. Expiration of sessions: You are aware that all packages are on a 4 week commitment, unless stated and agreed upon otherwise. If you fail to complete the scheduled sessions within allowed and agreed upon timeframe, you understand your training sessions will expire and that you are responsible to pay any remaining balance on your account.
6. Release of results upon program completion: Client photos and testimonials are requested upon completion of the first week and initial program completion of the last week.
7. Use of nutritional supplements: To guarantee safety, we request that all clients do not use any potentially dangerous stimulants like “diet” or “fat burning” pills of any kind.
Should be Empty:

Wellness Intake Form

Personal Information

Emergency Contact

Part 1: PreScreening Health Assessment

Photo/Video Consent

Before Training Questionnaire