Intake Form
Date
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Month
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Day
Year
Date
Mobile Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Name
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First Name
Last Name
Email
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example@example.com
Birthday
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Month
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Day
Year
Date
Height (Feet/Inches - ie 5'6)
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Gender
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Please Select
Female
Male
Tshirt Size for IPT Swag :)
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How did you hear about us?
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Health
Have you had any injuries, procedures, surgeries, or medical concerns we should know about?
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Medications/Supplements:
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Goals
What is your ultimate goal while working with Infinity Personal Training?
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What do you believe is hindering you from achieving your goals?
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What are you most excited about in our journey together?
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What are you most nervous about as we begin?
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Why do you want to make this change?
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What would make this program feel like a win in the first 60-90 days?
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How will you measure success after getting started?
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If you fall behind, what's the best way for us to help you reset?
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What usually gets in the way of your consistency? (work schedule, stress, family responsibilities, travel, emotional eating, weekends, lack of planning, low motivation, pain/injury, lack of support, all-or-nothing thinking, poor sleep)
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Lifestyle
Walk us through a typical week. What do your weekdays look like and how do your weekends differ?
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How much water do you drink a day?
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Do you consume alcohol? If Yes, how much/how often?
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Do you smoke or use tobacco products? If Yes, how much/how often?
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How many hours of sleep do you get per night consistently?
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How would you rate your stress level on scale of 1 to 10?
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Training
What have you tried in the past?
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What are you currently doing for exercise consistently?
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What is your average step count?
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What cardio or other equipment do you have access to at home?
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Outside of the training sessions with us, what feels more realistic to you? (Daily walks, at home workouts, hitting a step goal, etc.)
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Nutrition
Tell me about your typical eating routine. Who cooks? Are you cooking for anyone else or just yourself?
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How often do you eat out?
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Do you currently track your food and/or have you in the past?
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Explain your previous dieting history.
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What worked well ?
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What didn’t work and why are you no longer following it?
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Do you have any allergies or intolerances?
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Do you plan on including alcohol? If so, how often?
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Health Questionnaire
Do you feel pain in your chest when you do physical activity?
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Yes
No
Do you lose your 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
Is your doctor currently prescribing drugs for your blood pressure, cholesterol or heart condition?
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Yes
No
Do you have diabetes or other metabolic issues (thyroid, renal, liver)?
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Yes
No
Are you currently taking any medications for (select all that apply):
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Heart Issues
Mental Health
Pain
NONE
Your Ultimate Goal
Now we want to get clear on your most important goal.
What outcome do you most want to achieve? Pick one main goal. Examples: lose body fat, build muscle, gain strength, improve energy, improve confidence, reduce pain, improve endurance, improve health markers, maintain weight loss, improve consistency, improve body composition.
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Make your goal specific. Use the format below.
My specific goal is: "I want to [verb/action] from [current position] to [desired result] by [deadline]."
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We strongly recommend you consult with your physician before beginning or modifying your exercise regime. By signing below, you hereby represent, warrant and agree as follows:
You are in good health and have notified us of any pre-existing medical conditions that you have. You have consulted with your physician prior to participating in exercise activity at the studio, or you accept and assume all of the risks (including potential physical injury) related to participating in exercise activities without consulting your physician. We are not responsible for loss or damage to any valuables you bring to or store at the studio. If equipment is defective, I will not use it and I will report its condition to a staff member of the studio. I expressly agree and promise to accept and assume all of the risks existing in this activity. I hereby voluntarily release, forever discharge and agree to indemnify and hold harmless Infinity Personal Training (hereinafter collectively referred to as “IPT”), for any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of IPT’s equipment or facilities, including any such claims which allege the negligent acts or omissions of IPT. Should IPT or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. In the event that I file a lawsuit against IPT, I agree to do so solely in the state of Texas, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree to call or email IPT 3 hours before a scheduled session in order to change or cancel that session, otherwise I will be charged for the session. I agree that sessions paid in advance will be held as credits to my account. These credits cannot be redeemed for cash value. If 30 consecutive days pass with no activity to my account, unused sessions will be forfeited. As the parent and/or guardian signing below I assume full responsibility for and give the client signing below the ability to act as an agent of my consent for any membership contracts with IPT. By signing below, you acknowledge that you have read the foregoing, understand it, & agree to the terms.
Print Name (You or Parent/Guardian)
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Child's Name (If signing below for a minor.)
Signature
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